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202606662 <br />Surrogate Decision Making in Nebraska <br />Nebraska State Unit on Aging <br />SIGNATURE AND ACKNOWLEDGMENT <br />(CAUTION: This document MUST be signed IN THE PRESENCE of a notary to comply with the Nebraska <br />Uniform Power of Attorney Act) , <br />Your SignatureQr. <br />5 • 41' <br />Y cf <br />Your Name Printed <br />Date <br />-hi W. at. G kkiYt{ : dd ei , ,U e <br />Your Address <br />30$ Ce75—O2.3(c2 <br />Your Phone Number <br />NOTARY <br />State of Nebraska <br />[County] <br />[ �l of <br />) ss. <br />This document was acknowledged before me on <br />by c/PinC'f 5 f Lo <br />Name Principal <br />Fl <br />My commission expires: <br />of Notary <br />Power of Attorney, DC 6:12 PSC, Rev. 08/12 §30-4041 <br />Qtc0 <br />Date <br />©I <br />(Seal, if any) <br />NSKI <br />Wyk, Esp. miter24, 2025 <br />MLTC-PB-3 (99009) 2/21 <br />