221. Statements to be included in instrument.

An instrument conferring a lasting power of attorney1 must include, in addition to the prescribed information2, two statements by the donor:

  1.  

    (1)     to the effect that he has read the prescribed information or a prescribed part of it (or has had it read to him)3 and intends the authority conferred under the instrument to include authority to make decisions4 on his behalf in circumstances where he no longer has capacity5; and

  2.  

    (2)     either naming a person or persons whom the donor wishes to be notified of any application for the registration of the instrument6 or stating that there are