Policy Manual sample

MDT Home Health Care Agency, Inc. facility for the elderly or an employee of an operator of a residential care facility for the elderly. Witness Signature: ____________________________________ Witness Name: _______________________________________ Witness Address: _____________________________________________________ Date: Witness Signature: ____________________________________ Witness Name: ________________________________________ Witness Address: _______________________________________________________________ Date: At least one of the above witnesses must also sign the following declaration. I further declare under penalty of perjury under the laws of ______________, that I am not related to the Principal by blood, marriage, adoption, and, to the best of my knowledge, I am not entitled to any part of the estate of the Principal upon the death of the Principal under a will now existing or by operation of law. Signature: _________________________________________ Signature: __________________________________________ Home Health Agency Miscellaneous M-10