To legally appoint someone on your behalf to take any medical related decisions on your behalf in the State of Florida you may use this Florida Medical Power of Attorney Form. This form provided here is just a reference document and you may need to edit or modify the document to meet your requirements.
Text Version of The Form
AFFIDAVIT OF AGENT FORM
STATE OF _______________
COUNTY OF ______________
Before me, the undersigned authority, personally appeared _________________ (agent) (“Affiant”), who swore or affirmed that:
1. Affiant is the agent named in the Power of Attorney executed by _________________ (“Principal”) on _______________ (date).
2. This Power of Attorney is currently exercisable by Affiant. The principal is domiciled in ________________ (insert state, territory, or foreign country).
3. To the best of the Affiant’s knowledge after diligent search and inquiry:
The Principal is not deceased;
Affiant’s authority has not been suspended by initiation of proceedings to determine incapacity or to appoint a guardian or guardian advocate; and
There has been no revocation, partial or complete termination of the Power of Attorney or of Affiant’s authority.
4. Affiant is acting within the scope of authority granted in the Power of Attorney.
5. Affiant agrees not to exercise any powers granted by the Power of Attorney if Affiant attains knowledge that it has been revoked, partially or completely terminated or suspended, or is no longer valid because of the death or adjudication of incapacity of the Principal.
Sworn to (or affirmed) and subscribed before me this the ____ day of ___________ (month), ________ (year), by _________________ (Affiant)
(Signature of Notary Public- State of Florida)
(Print, Type, or Stamp Commissioned Name of Notary Public)
Personally Known OR Produced Identification ______________________________
(Type of Identification Produced)
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