Minnesota Advance Directive

Information you will need

• Principal Name
• Agent Name
• Alternate Agent Name
• Agent Relation
• Alternate Agent Relation
• Agent Telephone Number
• Alternate Agent Telephone Number
• Agent Address
• Alternate Agent Address
• Limitations
• Additional Information
• Principal Signature Date
• Principal DOB
• Name of Executing Party
• Notary Only: Date
• Notary Only: Principal Name
• Notary Only: Day
• Notary Only: Month
• Notary Only: Year
• Principal Street
• Principal City, State, ZIP Code
• Principal Address Continued
• First Witness: Initials
• Second Witness: Initials

…and 27 more fields in the PDF.

Completed by the agent and the provider and the employee.

The form includes 1 signature line, a notary acknowledgment, a witness section.