State of Georgia
Advance Directive for Health Care
Witness Attestation
Declarant Acknowledgment & Witness Signatures
O.C.G.A. § 31-32-5
On this day of , , (declarant) signed the foregoing Advance Directive for Health Care in the presence of both witnesses named below, and declared it to be their advance directive.
The declarant appeared to be of sound mind and was not under duress, menace, fraud, or undue influence at the time of signing.
Each witness must check all boxes confirming they are not disqualified under O.C.G.A. § 31-32-5(b), then sign.
- I am not related to the declarant by blood, marriage, or adoption.
- I am not entitled to any portion of the declarant's estate by will or operation of law.
- I am not the declarant's attending physician, nor an employee of the attending physician.
- I am not an operator or employee of a healthcare facility in which the declarant is a patient or resident.
- I am not related to the declarant by blood, marriage, or adoption.
- I am not entitled to any portion of the declarant's estate by will or operation of law.
- I am not the declarant's attending physician, nor an employee of the attending physician.
- I am not an operator or employee of a healthcare facility in which the declarant is a patient or resident.
Signed and acknowledged before me by , declarant, in County, Georgia, on the date set forth above.
Affix official notary stamp here if notarizing. Notarization is optional under O.C.G.A. § 31-32-5 — the two witness signatures are the legal requirement. The notary is not an attorney and cannot provide legal advice.
