• Task:Fill out the power of attorney and healthcare directive forms.
• Purpose:This will help you to become more familiar with legal forms used near the end of life, along with their general purpose in the field of healthcare.

Uniform Statutory Form Power of Attorney

(California Probate Code Section 4401)

NOTICE: THE POWERS GRANTED BY THIS DOCUMENT ARE BROAD AND SWEEPING. THEY ARE EXPLAINED IN THE UNIFORM STATUTORY FORM POWER OF ATTORNEY ACT (CALIFORNIA PROBATE CODE SECTIONS 4400-4465). THE POWERS LISTED IN THIS DOCUMENT DO NOT INCLUDE ALL POWERS THAT ARE AVAILABLE UNDER THE PROBATE CODE. ADDITIONAL POWERS AVAILABLE UNDER THE PROBATE CODE MAY BE ADDED BY SPECIFICALLY LISTING THEM UNDER THE SPECIAL INSTRUCTIONS SECTION OF THIS DOCUMENT. IF YOU HAVE ANY QUESTIONS ABOUT THESE POWERS, OBTAIN COMPETENT LEGAL ADVICE. THIS DOCUMENT DOES NOT AUTHORIZE ANYONE TO MAKE MEDICAL AND OTHER HEALTHCARE DECISIONS FOR YOU. YOU MAY REVOKE THIS POWER OF ATTORNEY IF YOU LATER WISH TO DO SO.

I, ________________________________________________ (your name and address) appoint ________________________________________________ (name and address of the person appointed, or of each person appointed if you want to designate more than one) as my agent (attorney-in-fact) to act for me in any lawful way with respect to the following initialed subjects:

TO GRANT ALL OF THE FOLLOWING POWERS, INITIAL THE LINE IN FRONT OF (N) AND IGNORE THE LINES IN FRONT OF THE OTHER POWERS.

TO GRANT ONE OR MORE, BUT FEWER THAN ALL, OF THE FOLLOWING POWERS, INITIAL THE LINE IN FRONT OF EACH POWER YOU ARE GRANTING.

TO WITHHOLD A POWER, DO NOT INITIAL THE LINE IN FRONT OF IT. YOU MAY, BUT NEED NOT, CROSS OUT EACH POWER WITHHELD.

__________(A)Real property transactions.

__________(B)Tangible personal property transactions.

__________(C)Stock and bond transactions.

__________(D)Commodity and option transactions.

__________(E)Banking and other financial institution transactions.

__________(F)Business operating transactions.

__________(G)Insurance and annuity transactions.

__________(H)Estate, trust, and other beneficiary transactions.

__________(I)Claims and litigation.

__________(J)Personal and family maintenance.

__________(K)Benefits from social security, medicare, medicaid, or othergovernmental programs, or civil or military service.

__________(L)Retirement plan transactions.

__________(M)Tax matters.

__________(N)ALL OF THE POWERS LISTED ABOVE.

YOU NEED NOT INITIAL ANY OTHER LINES IF YOU INITIAL LINE (N).

SPECIAL INSTRUCTIONS:

ON THE FOLLOWING LINES YOU MAY GIVE SPECIAL INSTRUCTIONS LIMITING OR EXTENDING THE POWERS GRANTED TO YOUR AGENT.________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

______________________________________________________________________

______________________________________________________________________

UNLESS YOU DIRECT OTHERWISE ABOVE, THIS POWER OF ATTORNEY IS EFFECTIVE IMMEDIATELY AND WILL CONTINUE UNTIL IT IS REVOKED.

This power of attorney will continue to be effective even though I become incapacitated.

STRIKE THE PRECEDING SENTENCE IF YOU DO NOT WANT THIS POWER OF ATTORNEY TO CONTINUE IF YOU BECOME INCAPACITATED.

EXERCISE OF POWER OF ATTORNEY WHERE

MORE THAN ONE AGENT DESIGNATED

If I have designated more than one agent, the agents are to act ________________________________.

IF YOU APPOINTED MORE THAN ONE AGENT AND YOU WANT EACH AGENT TO BE ABLE TO ACT ALONE WITHOUT THE OTHER AGENT JOINING, WRITE THE WORD "SEPARATELY" IN THE BLANK SPACE ABOVE. IF YOU DO NOT INSERT ANY WORD IN THE BLANK SPACE, OR IF YOU INSERT THE WORD "JOINTLY," THEN ALL OF YOUR AGENTS MUST ACT OR SIGN TOGETHER.

I agree that any third party who receives a copy of this document may act under it. Revocation of the power of attorney is not effective as to a third party until the third party has actual knowledge of the revocation. I agree to indemnify the third party for any claims that arise against the third party because of reliance on this power of attorney.

Signed this ____ day of _________________________, 20____.

________________________________________

(your signature)

State of ________________________, County of _________________________,

BY ACCEPTING OR ACTING UNDER THE APPOINTMENT, THE AGENT ASSUMES THE FIDUCIARY AND OTHER LEGAL RESPONSIBILITIES OF AN AGENT.

CERTIFICATE OF ACKNOWLEDGMENT OF NOTARY PUBLIC

State of California

County of ________________________

On ________________________, 20____, before me, ________________________, personally appeared ________________________, who proved to me on the basis of satisfactory evidence to be the person(s) whosename(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which theperson(s) acted, executed the instrument.

I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct.

WITNESS my hand and official seal.

Signature __________________________________(Seal, if any)

Notice to Person Executing Durable Power of Attorney

A durable power of attorney is an important legal document. By signing the durable power of attorney, you are authorizing another person to act for you, the principal. Before you sign this durable power of attorney, you should know these important facts:

Your agent (attorney-in-fact) has no duty to act unless you and your agent agree otherwise in writing.

This document gives your agent the powers to manage, dispose of, sell, and convey your real and personal property, and to use your property as security if your agent borrows money on your behalf. This document does not give your agent the power to accept or receive any of your property, in trust or otherwise, as a gift, unless you specifically authorize the agent to accept or receive a gift.

Your agent will have the right to receive reasonable payment for services provided under this durable power of attorney unless you provide otherwise in this power of attorney.

The powers you give your agent will continue to exist for your entire lifetime, unless you state that the durable power of attorney will last for a shorter period of time or unless you otherwise terminate the durable power of attorney. The powers you give your agent in this durable power of attorney will continue to exist even if you can no longer make your own decisions respecting the management of your property.

You can amend or change this durable power of attorney only by executing a new durable power of attorney or by executing an amendment through the same formalities as an original. You have the right to revoke or terminate this durable power of attorney at any time, so long as you are competent.

This durable power of attorney must be dated and must be acknowledged before a notary public or signed by two witnesses. If it is signed by two witnesses, they must witness either (1) the signing of the power of attorney or (2) the principal's signing or acknowledgment of his or her signature. A durable power of attorney that may affect real property should be acknowledged before a notary public so that it may easily be recorded.

You should read this durable power of attorney carefully. When effective, this durable power of attorney will give your agent the right to deal with property that you now have or might acquire in the future. The durable power of attorney is important to you. If you do not understand the durable power of attorney, or any provision of it, then you should obtain the assistance of an attorney or other qualified person.

Notice to Person Accepting the Appointment as Attorney-in-Fact

By acting or agreeing to act as the agent (attorney-in-fact) under this power of attorney you assume the fiduciary and other legal responsibilities of an agent. These responsibilities include:

1. The legal duty to act solely in the interest of the principal and to avoid conflicts of interest.

2. The legal duty to keep the principal's property separate and distinct from any other property owned or controlled by you.

You may not transfer the principal's property to yourself without full and adequate consideration or accept a gift of the principal's property unless this power of attorney specifically authorizes you to transfer property to yourself or accept a gift of the principal's property. If you transfer the principal's property to yourself without specific authorization in the power of attorney, you may be prosecuted for fraud and/or embezzlement. If the principal is 65 years of age or older at the time that the property is transferred to you without authority, you may also be prosecuted for elder abuse under Penal Code Section 368. In addition to criminal prosecution, you may also be sued in civil court.

I have read the foregoing notice and I understand the legal and fiduciary duties that I assume by acting or agreeing to act as the agent (attorney-in-fact) under the terms of this power of attorney.

Signature of Agent: __________________________________ Date: ______________

Print Name of Agent: __________________________________

State of California

ADVANCE HEALTH CARE DIRECTIVE

This document may be used to make your wishes known regarding what medical treatment or care you do or do not want to receive in the event you are unable to speak for yourself. You should provide a copy to your doctor, family, and friends.

I.ADVANCE HEALTH CARE DECLARATION

I, ________________________, being of sound mind and legal age, willfully and voluntarily make this declaration to state my desires regarding health care treatment if I am unable to speak for myself. It is my intention that this declaration be honored by my family, my physicians, and all others who may partake in my healthcare.

II.DEFINITIONS

"Artificial nutrition and hydration" is food, supplements, or fluids provided through intravenous (IV) therapy or a feeding tube.

"Life-sustaining treatment" is any mechanical or artificial treatment, procedure, or medication that would prolong the process of dying. Examples of such treatment include antibiotics, artificial respiration, cardiopulmonary resuscitation (CPR), dialysis, transfusions, and ventilation.

"Permanent unconscious state" is a total loss of consciousness from which I am unlikely to recover in the near future. Examples include a persistent vegetative state and irreversible coma.

"Terminal condition" is an irreversible illness that will likely result in my death or a state of permanent unconsciousness from which I am unlikely to recover in the near future.

III.POWER OF ATTORNEY FOR HEALTH CARE

DESIGNATION OF AGENT

In the event I have a terminal condition or am in a permanent unconscious state, or am otherwise unable to speak for myself, I designate the following individual as my agent to make health care decisions for me:

Agent'sFull Name

Agent'sAddress

City

State

Zip Code

Agent'sHome Phone

Agent's Other Phone

DESIGNATION OF ALTERNATE AGENT(S)

If I revoke my agent's authority or if my agent is not willing, able, or reasonably available to make a health care decision for me, I designate as my first alternate agent:

First Alternate Agent'sFull Name

First Alternate Agent'sAddress

City

State

Zip Code

First Alternate Agent'sHome Phone

First Alternate Agent's Other Phone

If I revoke the authority of my agent and first alternate agent or if neither is willing, able, or reasonably available to make a health care decision for me, I designate as my second alternate agent:

Second Alternate Agent'sFull Name

Second Alternate Agent'sAddress

City

State

Zip Code

Second Alternate Agent'sHome Phone

Second Alternate Agent's Other Phone

AGENT'SAUTHORITY

My agent is authorized to make all health care decisions for me, including decisions to provide, withhold, or withdraw life-sustaining treatment, artificial nutrition and hydration, and all other forms of health care treatment to keep me alive, except as I state here:

________________________________________________________________________________________________________________________________________________________________________

WHEN AGENT'SAUTHORITY BECOMES EFFECTIVE

(PLEASE INITIAL ONE)

My agent's authority becomes effective:

______When I become incapacitated and cannot make health care decisions on my own.

______Immediately upon the effective execution of this document.

AGENT'SOBLIGATION

I direct my agent to make health care decisions for me in accordance with this documents and my other wishes to the extent known to my agent. If my wishes are unknown, my agent shall make health care decisions for me to promote in my best interests and my personal values.

HIPPA WAIVER

(PLEASE INITIAL ONE)

______I authorize my health care providers to release my protected health information and medical records to my agent during the period my agent's authority is effective.

______I DO NOT authorize my health care providers to release my protected health information and medical records to my agent.

NOMINATION OF GUARDIAN OR CONSERVATOR

If a guardian conservator needs to be appointed for me by a court, I nominate to act as conservator:

Conservator'sFull Name

Conservator'sAddress

City

State

Zip Code

Conservator'sHome Phone

Conservator's Other Phone

If the person named above is not willing, able, or reasonably available to act as conservator, I nominate to act as first alternate conservator:

First Alternate Conservator'sFull Name

First Alternate ConservatorsAddress

City

State

Zip Code

First Alternate Conservator'sHome Phone

First Alternate Conservator'sWork Phone

If the persons named above are willing, able, or reasonably available to act as conservator, I nominate as second alternate conservator:

Second Alternate Conservator'sFull Name

Second Alternate ConservatorsAddress

City

State

Zip Code

Second Alternate Conservator'sHome Phone

________________________

Second Alternate Conservator'sWork Phone

IV.LIVING WILL

TERMINAL CONDITION

LIFE-SUSTAINING TREATMENT:

If I become ill and have a terminal condition:

(PLEASE INITIAL ONE)

______I direct that life-sustaining measures be administered to prolong my life.

______I DO NOT want life-sustaining measures to administered.

______I direct that my agent decide.

ARTIFICIAL NUTRITION AND HYDRATION:

(PLEASE INITIAL ONE)

______I direct that artificial nutrition and hydration be administered regardless of my condition.

______I DO NOT want artificial nutrition and hydration to be administered regardless of my condition.

______I direct that my agent decide.

PERMANENT UNCONSCIOUS STATE

LIFE-SUSTAINING TREATMENT:

If I become ill and fall into a permanent unconscious state:

(PLEASE INITIAL ONE)

______I direct that life-sustaining measures be administered to prolong my life.

______I DO NOT want life-sustaining measures to administered.

______I direct that my agent decide.

ARTIFICIAL NUTRITION AND HYDRATION:

(PLEASE INITIAL ONE)

______I direct that artificial nutrition and hydration be administered regardless of my condition.

______I DO NOT want artificial nutrition and hydration to be administered regardless of my condition.

______I direct that my agent decide.

RELIEF FROM PAIN

(PLEASE INITIAL ONE)

______I direct that treatment for the alleviation of pain or discomfort be administered, even if it results in the hastening of my death.

______I DO NOT want treatment for the alleviation of pain or discomfort be administered, even if it results in the hastening of my death.

OTHER WISHES

___________________________________________________________________________________

___________________________________________________________________________________

V.DONATION OF ORGANS AT DEATH

Upon my death:

(PLEASE INITIAL ONE)

______I give any needed organs, tissues, or parts

______I give the following organs, tissues or parts only: _____________________________________

for the following purposes: (INITIAL ALL THAT APPLY)

______therapy

______transplant

______research

______education

______other: _______________

______I DO NOT wish to make an anatomical donation.

______I authorize my agent to donate all or any part of my body for any purposes my agent sees fit.

VI.FINAL ARRANGEMENTS

Upon my death, I direct that my body:

(PLEASE INITIAL ONE)

______be interred at ________________________________________.

______be cremated and placed at ________________________________________.

______other: ________________________________________

______Upon my death, I authorize my agent to organize my funeral arrangements and provide for the disposition of my body as my agent sees fit.

Other Instructions: ____________________________________________________________________

___________________________________________________________________________________

VII.PRIMARY PHYSICIAN

The following physician shall be my primary physician:

Name: ________________________

Address: ________________________________________

Telephone Number: ________________________

ALTERNATE PRIMARY PHYSICIAN

If the physician above is unable to act as my primary physician, the following physician shall be my primary physician:

Name: ________________________

Address: ________________________________________

Telephone Number: ________________________

VIII.SIGNATURE

YourSignature

Date

YourName

YourAddress

City

State

Zip Code

IX.ACKNOWLEDGMENT BY AGENT

I hereby accept and agree to serve as health care agent, and act in accordance with the principal's desires as expressed in this document or otherwise known to me.

Agent'sSignature

Date

First Alternate Agent'sSignature

Date

Second Alternate Agent'sSignature

Date

X.WITNESS ATTESTATION AND SIGNATURES

We declare that the principal who signed this document:

1.Is personally known to us or provided proof of identity;

2.Signed this document in our presence; and

3.Appeared to be of sound mind and free from duress or undue influence.

We are not the individual(s) appoint as the principal's agent or the health care provider or employee of the health care provider of theprincipal.

FIRST WITNESS

First Witness'Signature

Date

First Witness'Name

First Witness'Address

City

State

Zip Code

SECOND WITNESS

Second Witness'Signature

Date

Second Witness'Name

Second Witness'Address

City

State

Zip Code

ADDITIONAL STATEMENT OF WITNESSES

At least one of the above witnesses must also sign the following declaration:

I further declare under penalty of perjury under the laws of California that I am not related to the individual executing this document by blood, marriage, or adoption, and to the best of my knowledge, I am not entitled to any part of the individual's estate upon his or her death under a will now existing or by operation of law.

_________________________________________________________________

First Witness'SignatureSecond Witness'Signature

ACKNOWLEDGEMENT OF NOTARY PUBLIC

State of California

County of _________________

On ________________________ before me, ________________________ personally appeared ________________________, who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her authorized capacity, and that by his/her signature on the instrument the person, or the entity upon behalf of which the person acted, executed the instrument.

I certify under PENALTY OF PERJURY under the laws of the State of _________________ that the foregoing paragraph is true and correct.

WITNESS my hand and official seal.

Signature ______________________________

(SEAL)

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