The Person I Want to Make Health Care Decisions for Me When I Cannot Make Them for Myself

If I, [NAME], being of sound mind, am no longer able to make my own health care decisions, the person I choose as my Health Care Power of Attorney is:

Address: [ADDRESS, STREET, CITY, STATE, ZIP CODE]

Phone Number: [PHONE NUMBER]

I understand that my Health Care Power of Attorney can make health care decisions for me, including decisions concerning the withholding or withdrawal of life sustaining procedures. Such Health Care Power of Attorney has full authority to make such decisions as fully, completely and effectually, and to all intents and purposes with the same validity as if such decisions had been personally made by me.

This Health Care Power of Attorney is effective immediately and serves to revoke and supersede any prior Health Care Power of Attorney I have previously executed. This Health Care Power of Attorney will continue until it is revoked.

This declaration is made and signed by me on this [DAY] day of [MONTH], 20[XX], in the presence of the undersigned witnesses who are not entitled to any portion of my estate.

Signed: ________________________________________

Address: [ADDRESS, STREET, CITY, STATE, ZIP CODE]

Date of Birth: [DAY] day of [MONTH], [YEAR]

Social Security Number: [XXX-XX-XXXX]

WITNESS ACKNOWLEDGEMENT: The Declarant is and has personally been known to me, and I believe the Declarant to be of sound mind. I am not related to the Declarant by blood or marriage and would not be entitled to any portion of Declarant’s estate upon his/her death. I was physically present and personally witnessed the Declarant execute the foregoing Declaration.

________________________________________________

WITNESS SIGNATURE / Print Witness Name

[DAY] day of [MONTH], 20[XX], [TIME][AM/PM]

________________________________________________

WITNESS SIGNATURE / Print Witness Name

[DAY] day of [MONTH], 20[XX], [TIME][AM/PM]