Date: Name (Print):. Signature: Partnership, Corporation or Similar Entity: I designate.These sample forms may be useful when filing documents for the civil and family courts. If you have any questions, consult an attorney. These forms helpful when handling the estate of a deceased person. If you have questions, consult with an attorney. I have been a patient at your facility, or am the patient's authorized representative. I understand that the facility has legally protected. Talk to an admissions counselor in your area for guidance on your application as well as the financial aid process. How Do I Obtain an Apostille or Certification?