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Alaska : ____________________________________ 3 who acknowledged). ______________________________________________________ Signature of Person Taking Acknowledgement Title or Rank ___________________________________________ Serial Number, if any_________________________ ) 2 ACKNOWLEDGEMENT FORM The foregoing instrument was acknowledged before me this ___________________ (date) by ___________________________________________ (name of person___________________ (Witness Signature) Print Name: ___________________________________ Address: ______________________________________ State of _______________________________ ) ) Judicial District NESS FORM _____________________________________________ (Witness Signature) Print Name: ___________________________________ Address: ______________________________________ __________________________to take acknowledgments under AS 09.63.010 . The witness form below may be used for the two witnesses. The acknowledgement form below may be used for the person qualified to take acknowledgements. WIT______________ If another person is to sign for the declarant at the declarant's direction, the person signing for the declarant must sign in the presence of two persons or a person who is qualified ________________ Signed on: __________________________________________________ (date) Signature ____________________________________________________ Place: _________________________________________imitations: Organ: Heart Kidney(s) Liver 1 Lung(s) Pancreas Other: ______________________________________________________________________ ____________________________________________________________able for donation. OPTIONAL: In the event of my death, I donate the following part(s) of my body for the purposes identified in AS 13.50.020 Tissue: Eyes Bone and connective tissue Skin Heart Other: Lspital when a do not resuscitate order is to be implemented for me, I do not want the do not resuscitate order to take effect until the donated organ can be evaluated to determine if the organ is suitded by gastric tube or intravenously if necessary. Notwithstanding the other provisions of this declaration, if I have donated an organ under this declaration or by another method, and if I am in a hor withdraw procedures that merely prolong the dying process and are not necessary to my comfort or to alleviate pain. I [__] do [__] do not desire that nutrition or hydration (food and water) be provi by administration of life-sustaining procedures. If my condition is terminal and I am unable to participate in decisions regarding my medical treatment, I direct my attending physician to: withhold ondlegalforms.com Living Will DECLARATION If I should have an incurable or irreversible condition that will cause my death within a relatively short time, it is my desire that my life not be prolongedy possible tax consequences arising out of this document should be discussed with a tax professional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at fi be used or signed without consulting an attorney first to make sure it fits your particular situation. Advice from a local attorney is always recommended when dealing with estate planning matters. Anese forms are not intended and are not a substitute for legal and/or tax advice. Laws vary from time to time and from state to state. These forms should only be a starting point for you and should notThese forms are provided "as is" and no implied or express warranties have been made or are provided as to their suitability for any specific purpose or as to their legal effect or completeness. [_]Thdical or dental education, research, advancement of medical or dental science, therapy, or transplantation; or (4) a specified individual for therapy or transplantation needed by the individual. [_] transplantation; (2) an accredited medical or dental school, college or university for education, research, advancement of medical or dental science, or therapy; (3) a bank or storage facility, for me's body or a part of a decedent's body for the purposes stated: (1) a hospital, surgeon, or physician, for medical or dental education, research, advancement of medical or dental science, therapy, or revocation a part of the declarant's medical record. AS 13.50.020. Potential Donees and Purposes For Which Anatomical Gifts May Be Made. The following persons may become donees of gifts of a decedente provider by the declarant or by another to whom the revocation was communicated. Living Will Information & Instructions ­ Page 2 (b) The attending physician or health care provider shall make the ysical condition. A revocation is only effective as to the attending physician or any health care provider acting under the guidance of that physician upon communication to the physician or health carded in AS 13.50.050 for an anatomical gift, a declaration may be revoked at any time and in any manner by which the declarant is able to communicate an intent to revoke, without regard to mental or phn complies with this chapter and AS 13.50, and that the declaration, including any anatomical gift contained in the declaration, is valid. AS 18.12.020. Revocation of Declaration. (a) Except as provi below) (d) A physician or health care provider may presume, in the absence of actual notice to the contrary, that the declaration complies with this chapter, that an anatomical gift in the declaratior other health care provider who is provided a copy of the declaration shall make it a part of the declarant's medical records. (c) A declaration may, but need not, be in the following form: (see formAS 13.50.014 - 13.50.016 for an anatomical gift contained in the declaration, it is the responsibility of the declarant to provide a copy of the declaration to the declarant's physician. A physician o sign in the presence of two persons or a person who is qualified to take acknowledgements under AS 09.63.010 . A person may not charge a fee for preparing a declaration. (b) Except as provided under on the death of the person. The declaration shall be signed by the declarant, or another person at the declarant's direction. If signed by another person at the declarant's direction, the signer shalls condition is determined to be terminal and the declarant is not able to make treatment decisions, except that, if the declaration contains an anatomical gift under AS 13.50, the gift takes effect up18 years old may execute a declaration at any time directing that life-sustaining procedures be withheld or withdrawn from that person. The declaration is given operative effect only if the declarant'e, we have included useful excerpts from the Alaska Statutes relating to Living Wills. AS 18.12.010. Declaration Relating to Use of Life-Sustaining Procedures. (a) A competent person who is at least (1) Information and Instruction for Alaska Living Will; (2) Alaska Living Will. This Alaska Living Will is based on Title 18 Chapter 12 Section 10 et. Seq. of the Alaska Statutes. For your conve nienc_____________ on ______________________________ _________________________________________ (Signature of Officer or Notary) -2- Information and Instructions Alaska Living Will This package contains ___________, _______________. (month) (year) _________________________________________ (Signature of Principal) Acknowledged before me at _____________________________________________ _____________for appointment to serve as my guardian or conservator, or in any similar representative capacity. (§ 1 ch 109 SLA 1988) IN WITNESS WHEREOF, I have hereunto signed my name this ____ day (day) of ____ate __________________________________________________________ (name of conservator) at: ________________________________________________________ address of conservator) to be considered by the court g Will." I have not executed a "Living Will." APPOINTMENT OF GUARDIAN OR CONSERVATOR In the event that a court decides that it is necessary to appoint a guardian or conservator for me, I hereby nomine upon the date of my disability and shall not otherwise be affected by my disability. EXECUTION OF LIVING WILL (check one) o o I have executed a separate declaration under AS 18.12, known as a"Livin Alternate Attorney- in-Fact: _________________________________________ Address of Second Alternate Attorney- in-Fact: _______________________________________ -1- This document shall become effectivptional): Name of First Alternate Attorney- in-Fact: ___________________________________________ Address of First Alternate Attorney-in-Fact: __________________________________________ Name of Second to the full extent that I am permitted by law to act through an agent. If the agent named above is unable or unwilling to serve, then I appoint the following agent(s) to serve with the same powers (oact concerning my health care services in my name, place, and stead in any way which I myself could do, if I were personally present, with respect to the following matters, as defined in AS 13.26.344,______________________________________________________, (name of attorney- in-fact) of ______________________________________________________, (address of attorney- in- fact) my attorney- in- fact to ANY TIME. Pursuant to AS 13.26.338 et. Seq. I, _________________________________________, (name) of __________________________________________________________________ (address) do hereby appoint ___INGLY, THE FOLLOWING DOCUMENT SHOULD ONLY BE USED AFTER CAREFUL CONSIDERATION. IF YOU HAVE ANY QUESTIONS ABOUT THIS DOCUMENT, YOU SHOULD SEEK COMPETENT ADVICE. YOU MAY REVOKE THIS POWER OF ATTORNEY ATn affidavit, as required by law NOTICE TO PRINCIPAL THE POWERS GRANTED FROM THE PRINCIPAL TO THE AGENT OR AGENTS IN THE FOLLOWING DOCUMENT INCLUDE THE POWER TO MAKE YOUR HEALTH CARE DECISIONS. ACCORDe to comply with the statutory form power of attorney. If the power of attorney is one which becomes effective upon the disability of the principal, the disability of the principal is established by ary form power of attorney may be liable to the principal, the attorney- in-fact, the principal's heirs, assigns, or estate for a civil penalty, plus damages, costs, and fees associated with the failurpal's heirs, assigns, or estate as a result of permitting the attorney- in-fact to exercise the authority granted by the power of attorney. A third party who fails to honor a properly executed statutoble representations of an attorney- in-fact as to a matter relating to a power granted by a properly executed statutory power of attorney does not incur any liability to the principal or to the princind use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com -3- Power of Attorney for Health Care NOTICE TO THIRD PARTIES A third party who relies on the reasonalso consult an attorney whenever a document is negotiated with another party. Any possible tax consequences arising out of this document should be discussed with a tax professional. [_] The purchase ad should not be used without consulting with an attorney first. Before using or signing this document you should have an attorney review it to make sure it fits your particular situation. You should aeness. [_]These forms are not intended and are not a substitute for legal and/or tax advice. Laws vary from time to time and from state to state. These forms should only be a starting point for you an-being. [_] These forms are provided "as is" and no implied or express warranties have been made or are provided as to their suitability for any specific purpose or as to their legal effect or complet this subsection; and (9) do any other act or acts that the principal can do through an agent and that the agent considers desirable or necessary to provide for the principal's physical or mental wellutions; (8) hire, discharge, or compensate an attorney, accountant, expert witness, or assistant when the agent considers the action to be desirable for the proper execution of the powers described insions regarding mental health treatment; (6) arrange for care or lodging of the principal in a hospital, nursing home, or hospice; (7) grant releases to health care professionals or health care institnt is consistent with the wishes expressed in the declaration under AS 47.30.950 - 47.30.980 and if the principal has not designated another attorney- in- fact to have exclusive authority to make deciclaration under AS 47.30.950 - 47.30.980, the agent may consent to voluntary commitment or placement in a mental health treatment facility and electroconvulsive or electric-shock therapy if that conselacement in a mental health treatment facility, electroconvulsive or electric-shock therapy, psychosurgery, sterilization, or an abortion except that, if the principal has properly executed a -2- de-in- fact appointed under AS 47.30.950 47.30.980 has not withdrawn; (5) consent or refuse to consent to the principal's psychiatric care, but the consent does not authorize a voluntary commitment or p - 47.30.980 unless the principal has provided that an attorney-in- fact appointed under AS 47.30.950 - 47.30.980 shall have exclusive authority with regard to mental health treatment and the attorneyustaining procedures; (3) take all steps necessary to enforce a properly executed declaration under AS 18.12; (4) take all steps necessary to enforce a properly executed declaration under AS 47.30.950to others medical and related information and records; (2) consent or refuse to consent to medical care or relief for the principal from pain, but the agent may not authorize the termination of life-srvices shall be construed to mean that, as to the health care of the principal, whether to be provided in the state or elsewhere, the principal authorizes the agent to (1) have access to and disclose 344. Interpretation of Provisions in Statutory Form Power of Attorney. (partial) ( l ) In the statutory form power of attorney, the language conferring general authority with respect to health care seically listing additional powers of the agent; or (3) makes an additional provision that is not substantially inconsistent with the other provisions of the statutory form power of attorney. AS 13.26.e or more of the powers enumerated in one or more of the subsections of AS 13.26.344 with respect to a section of the statutory form power of attorney that is not eliminated by the principal by specifof the powers enumerated in one or more of the subsections of AS 13.26.344 with respect to a section of the statutory form power of attorney that is not eliminated by the principal; (2) supplements onS 13.26.332 - 13.26.344 is not prevented from being a statutory form power of attorney by the fact that it also contains additional language that (1) eliminates from the power of attorney one or more he instrument, the instrument shall continue in effect until revoked. -1- AS 13.26.347. Validity of Modified Statutory Form Power of Attorney. A power of attorney that satisfies the requirements of Ahe principal's subsequent disability on the instrument, the instrument shall be revoked by the subsequent disability of the principal; (4) if the principal has failed to indicate a specific term for ted that the instrument shall become effective upon the date of the principal's signature or has failed to indicate when the instrument shall become effective and has failed to indicate the effect of t) if the principal has failed to indicate when the instrument shall become effective, the instrument shall become effective upon the date of the principal's signature; (3) if the principal has indicathe principal has appointed more than one person to act as attorney-in- fact or agent and failed to check whether the agents may act "jointly" or "severally," the agents are required to act jointly; (2nly if they conform to the requirements of AS 13.26.347. AS 13.26.341. Applicability of Provisions of Statutory Form Power of Attorney. In the instrument set out in AS 13.26.332 - 13.26.335, (1) if tne through the text of any category for which the principal does not desire to give the agent authority. (b) Special provisions and limitations may be imposed on the statutory form power of attorney oubstantially the following form (see form below): AS 13.26.338. Completion of Statutory Form Power of Attorney. (a) In the instrument set out in AS 13.26.332 - 13.26.335, the principal must draw a li. AS 13.26.332. Statutory Form Power of Attorney. A person who wishes to designate another as attorney- in- fact or agent by a power of attorney may execute a statutory power of attorney set out in sre is based on Title 13 Chapter 26 Section 332 et. Seq. of the Alaska Statutes. The following are useful excerpts from the Alaska Statutes relating to the Alaska Power of Attorney for Health Care Form Care This package contains (1) Information and Instruction for Alaska Power of Attorney for Health Care; (2) Alaska Power of Attorney for Health Care Form. This Alaska Power of Attorney for Health Caa tax professional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Information and Instructions Alaska Power of Attorney for Healthparticular situation. Advice from a local attorney is always recommended when dealing with estate planning matters. Any possible tax consequences arising out of this document should be discussed with aws vary from time to time and from state to state. These forms should only be a starting point for you and should not be used or signed without consulting an attorney first to make sure it fits your de or are provided as to their suitability for any specific purpose or as to their legal effect or completeness. [_]These forms are not intended and are not a substitute for legal and/or tax advice. L Care Directive. The first form is the Power of Attorney for Health Care and the second form is the Living Will. [_] These forms are provided "as is" and no implied or express warranties have been maAlaska Advance Health Care Directive This package contains both a Alaska Power of Attorney for Health Care and a Alaska Living Will. Together these forms are also sometimes known as an Advance Health Alaska