154.03(3)(k)12.12. 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.

AFFIDAVIT OF COMPLIANCE

The undersigned, being first duly sworn under oath, states as follows:

This 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].

1. The name and residential address of the declarant is ....

2. The name and [residential or business] address of remote witness 1 is ....

3. The name and [residential or business] address of remote witness 2 is ....

4. 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 ....

5. 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 ....

6. 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 ....

7. 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:

8. 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.

9. 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.

10. The audiovisual technology used for the signing process was ....

11. The declaration to health care professionals was not signed in counterpart. The following methods were used to forward the declaration to health care professionals to each remote witness for signing and to the supervising attorney after signing. - OR - The declaration to health care professionals was signed in counterpart. The following methods were used to forward each counterpart to the supervising attorney. [If applicable] - 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 on [date] by [e.g., attaching page 7 from each counterpart signed by a remote witness to the back of the declaration to health care professionals signed by the declarant].