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Alaska ________________ __________________________ on ______________________________ _________________________________________ (Signature of Officer or Notary) -2- name this ____ day (day) of _______________, _______________. (month) (year) _________________________________________ (Signature of Principal) Acknowledged before me at _____________________________r) to be considered by the court 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 onservator for me, I hereby nominate __________________________________________________________ (name of conservator) at: ________________________________________________________ address of conservaton under AS 18.12, known as a"Living 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 c1- This document shall become effective upon the date of my disability and shall not otherwise be affected by my disability. EXECUTION OF LIVING WILL (check one) I have executed a separate declaratio__________________________ Name of Second Alternate Attorney-in-Fact: _________________________________________ Address of Second Alternate Attorney-in-Fact: _______________________________________ -g agent(s) to serve with the same powers (optional): Name of First Alternate Attorney-in-Fact: ___________________________________________ Address of First Alternate Attorney-in-Fact: ________________lowing matters, as defined in AS 13.26.344, 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 followinf attorney-in-fact) my attorney-in-fact to act 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 fol________________ (address) do hereby appoint _________________________________________________________, (name of attorney-in-fact) of ______________________________________________________, (address o ADVICE. YOU MAY REVOKE THIS POWER OF ATTORNEY AT ANY TIME. Pursuant to AS 13.26.338 et. Seq. I, _________________________________________, (name) of __________________________________________________ POWER TO MAKE YOUR HEALTH CARE DECISIONS. ACCORDINGLY, THE FOLLOWING DOCUMENT SHOULD ONLY BE USED AFTER CAREFUL CONSIDERATION. IF YOU HAVE ANY QUESTIONS ABOUT THIS DOCUMENT, YOU SHOULD SEEK COMPETENThe disability of the principal is established by an affidavit, as required by law NOTICE TO PRINCIPAL THE POWERS GRANTED FROM THE PRINCIPAL TO THE AGENT OR AGENTS IN THE FOLLOWING DOCUMENT INCLUDE THEamages, costs, and fees associated with the failure 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, tarty who fails to honor a properly executed statutory 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 dncur any liability to the principal or to the principal'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 pTHIRD PARTIES A third party who relies on the reasonable 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 idiscussed with a tax professional. [_] The purchase and 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 sure it fits your particular situation. You should also consult an attorney whenever a document is negotiated with another party. Any possible tax consequences arising out of this document should be hese forms should only be a starting point for you and should not be used without consulting with an attorney first. Before using or signing this document you should have an attorney review it to makeecific 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. Laws vary from time to time and from state to state. To provide for the principal's physical or mental well-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 spe for the proper execution of the powers described in 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 tes to health care professionals or health care institutions; (8) hire, discharge, or compensate an attorney, accountant, expert witness, or assistant when the agent considers the action to be desirablrney-in-fact to have exclusive authority to make decisions regarding mental health treatment; (6) arrange for care or lodging of the principal in a hospital, nursing home, or hospice; (7) grant releasectroconvulsive or electric-shock therapy if that consent 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 attothat, if the principal has properly executed a -2- declaration under AS 47.30.950 - 47.30.980, the agent may consent to voluntary commitment or placement in a mental health treatment facility and el consent does not authorize a voluntary commitment or placement in a mental health treatment facility, electroconvulsive or electric-shock therapy, psychosurgery, sterilization, or an abortion except with regard to mental health treatment and the attorney-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 thenforce a properly executed declaration under AS 47.30.950 - 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 authoritybut the agent may not authorize the termination of life-sustaining procedures; (3) take all steps necessary to enforce a properly executed declaration under AS 18.12; (4) take all steps necessary to e authorizes the agent to (1) have access to and disclose to others medical and related information and records; (2) consent or refuse to consent to medical care or relief for the principal from pain, nferring general authority with respect to health care services shall be construed to mean that, as to the health care of the principal, whether to be provided in the state or elsewhere, the principalisions of the statutory form power of attorney. AS 13.26.344. Interpretation of Provisions in Statutory Form Power of Attorney. (partial) ( l ) In the statutory form power of attorney, the language coattorney that is not eliminated by the principal by specifically listing additional powers of the agent; or (3) makes an additional provision that is not substantially inconsistent with the other provhat is not eliminated by the principal; (2) supplements one 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 hat (1) eliminates from the power of attorney one 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 t. A power of attorney that satisfies the requirements of AS 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 tthe principal has failed to indicate a specific term for the instrument, the instrument shall continue in effect until revoked. -1- AS 13.26.347. Validity of Modified Statutory Form Power of Attorneyecome effective and has failed to indicate the effect of the principal's subsequent disability on the instrument, the instrument shall be revoked by the subsequent disability of the principal; (4) if he principal's signature; (3) if the principal has indicated that the instrument shall become effective upon the date of the principal's signature or has failed to indicate when the instrument shall bor "severally," the agents are required to act jointly; (2) if the principal has failed to indicate when the instrument shall become effective, the instrument shall become effective upon the date of the instrument set out in AS 13.26.332 - 13.26.335, (1) if the 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" ons may be imposed on the statutory form power of attorney only 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 tut in AS 13.26.332 - 13.26.335, the principal must draw a line through the text of any category for which the principal does not desire to give the agent authority. (b) Special provisions and limitatitorney may execute a statutory power of attorney set out in substantially the following form (see form below): AS 13.26.338. Completion of Statutory Form Power of Attorney. (a) In the instrument set oes relating to the Alaska Power of Attorney for Health Care Form. 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 ator Health Care Form. This Alaska Power of Attorney for Health Care is based on Title 13 Chapter 26 Section 332 et. Seq. of the Alaska Statutes. The following are useful excerpts from the Alaska StatutInformation and Instructions Alaska Power of Attorney for Health Care This package contains (1) Information and Instruction for Alaska Power of Attorney for Health Care; (2) Alaska Power of Attorney f Alaska