AB985,,1091091. The name and residential address of the declarant.
AB985,,1101102. The name and residential or business address of each remote witness.
AB985,,1111113. The address within this state where the declarant was physically located at the time the declarant signed the declaration to health care professionals.
AB985,,1121124. The address within this state where each remote witness was physically located at the time the remote witness witnessed the declarant’s execution of the declaration to health care professionals.
AB985,,1131135. A statement that the declarant and remote witnesses were all known to each other and the supervising attorney or a description of the form of photo identification used to confirm the identity of the declarant and each remote witness.
AB985,,1141146. Confirmation that the declarant declared that the declarant is 18 years of age or older, that the document is the declarant’s declaration to health care professionals, and that the document was being executed as the declarant’s voluntary act.
AB985,,1151157. Confirmation that each of the remote witnesses and the supervising attorney were able to see the declarant, or an individual 18 years of age or older at the express direction and in the physical presence of the declarant, sign, and that the declarant appeared to be 18 years of age or older and acting voluntarily.
AB985,,1161168. A description of the audiovisual technology used for the signing process.
AB985,,1171179. If the declaration to health care professionals was not signed in counterpart, a description of the method used to forward the declaration to health care professionals to each remote witness for signing and to the supervising attorney after signing.
AB985,,11811810. If the declaration to health care professionals was signed in counterpart, a description of the method used to forward each counterpart to the supervising attorney and, if applicable, how and when the supervising attorney physically compiled the signed paper counterparts into a single document containing the declaration to health care professionals, the signature of the declarant, and the signatures of the remote witnesses.
AB985,,11911911. The name, state bar number, and business or residential address of the supervising attorney.
AB985,,12012012. Any other information that the supervising attorney considers to be material with respect to the declarant’s capacity to sign a valid declaration to health care professionals, the declarant’s and witnesses’ compliance with this section, or any other information that the supervising attorney deems relevant to the execution of the declaration to health care professionals.
AB985,,121121(L) The affidavit of compliance is attached to the declaration to health care professionals.
AB985,,122122(m) An affidavit of compliance described in this subsection shall be substantially in the following form:
AB985,,123123AFFIDAVIT OF COMPLIANCE
AB985,,124124State of ....
AB985,,125125County of ....
AB985,,126126The undersigned, being first duly sworn under oath, states as follows:
AB985,,127127This Affidavit of Compliance is executed pursuant to Wis. Stat. § 154.03 (3) to document the execution of the declaration to health care professionals of [name of declarant] via remote appearance by 2-way, real-time audiovisual communication technology on [date].
AB985,,1281281. The name and residential address of the declarant is ....
AB985,,1291292. The name and [residential or business] address of remote witness 1 is ....
AB985,,1301303. The name and [residential or business] address of remote witness 2 is ....
AB985,,1311314. The address within the state of Wisconsin where the declarant was physically located at the time the declarant signed the declaration to health care professionals is ....
AB985,,1321325. The address within the state of Wisconsin where remote witness 1 was physically located at the time the remote witness witnessed the declarant’s execution of the declaration to health care professionals is ....
AB985,,1331336. The address within the state of Wisconsin where remote witness 2 was physically located at the time the remote witness witnessed the declarant’s execution of the declaration to health care professionals is ....
AB985,,1341347. The declarant and remote witnesses were all known to each other and to the supervising attorney. - OR - The declarant and remote witnesses were not all known to each other and to the supervising attorney. Each produced the following form of photo identification to confirm his or her identity:
AB985,,135135....
AB985,,1361368. The declarant declared that the declarant is 18 years of age or older, that the document is the declarant’s declaration to health care professionals, and that the document was being executed as the declarant’s voluntary act.
AB985,,1371379. Each of the remote witnesses and the supervising attorney were able to see the declarant sign. The declarant appeared to be 18 years of age or older and acting voluntarily.