I, __________________(“Physician”), with offices at __________________________, hereby state that _____________________ (“Individual”) of ______________________, is fully and completely mentally competent in the broadest meaning of that term, and fully capable of taking independent actions as a completely mentally competent person.

___________________                Date:
Physician

___________________
Witness

Physician’s Statement of Mental Competency
Review List

This review list is provided to inform you about the document in question and assist you in its preparation.  This document should accompany any Power of Attorney, if possible.  It helps short circuit any challenges to the Power of Attorney.

1. Make multiple copies and have them attached to the Power of Attorney statement, in your distribution of it and storing of them.