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Arizona _______________________________ Time: ________________________________________ 2 _ Signature of Witness Date: ________________________________________ Time: ________________________________________ _____________________________________________ Signature of Witness Date: _________signed the declaration) and I signed the declaration as a witness in the presence of the declarant. I am competent and at least eighteen (18) years of age. ____________________________________________has been personally known to me, and I believe him or her to be of sound mind. I saw the declarant sign the declaration in my presence (or the declarant acknowledged in my presence that he or she had ________________________________________ Signature of Principal Date: _______________________________________________ (Note: This document may be notarized instead of being witnessed.) The declarant will is made under section 36-3262 et. Al. of the Arizona Revised Statutes, and continues in effect for all who may rely on it except those to whom I have given notice of its revocation. ____________e _________ I have not _____________ attached additional special provisions or limitations to this document to be honored in the absence of my being able to give health care directions. 1 This livingversible and incurable or I am in a persistent vegetative state. ____________________ 5. I want my life to be prolonged to the greatest extent possible. Other or Additional Statements of Desires I hav_____________ 4. Notwithstanding my other directions I do want the use of all medical care necessary to treat my condition until my doctors reasonably conclude that my condition is terminal or is irreant life-sustaining treatment withheld or withdrawn if it is possible that the embryo/fetus will develop to the point of live birth with the continued application of life-sustaining treatment. _______inistered food and fluids. ____________________ (c) To be taken to a hospital if at all avoidable. ____________________ 3. Notwithstanding my other directions, if I am known to be pregnant, I do not wt I do not want the following: ____________________ (a) Cardiopulmonary resuscitation, for example, the use of drugs, electric shock and artificial breathing. ____________________ (b) Artificially admible coma or a persistent vegetative state that my doctors reasonably feel to be irreversible or incurable, I do want the medical treatment necessary to provide care that would keep me comfortable, buI do not want life-sustaining treatment, beyond comfort care, that would serve only to artificially delay the moment of my death. ____________________ 2. If I am in a terminal condition or an irreversnation of paragraphs 1, 2, 3 and 4 but if you initial paragraph 5 the others should not be initialed.) ____________________ 1. If I have a terminal condition I do not want my life to be prolonged and ements carefully before you initial your selection. You can also write your own statement concerning life-sustaining treatment and other matters relating to your health care. You may initial any combiing Will DECLARATION (Some general statements concerning your health care options are outlined below. If you agree with one of the statements, you should initial that statement. Read all of these statuences 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 findlegalforms.com Livthout 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. Any possible tax conseqended 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 not be used or signed wided "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. [_]These forms are not intuired to, state the person's desires in a living will. The following form is offered as a sample only and does not prevent a person from using other language or another form: [_] These forms are provith care power of attorney, the agent must make health care decisions that are consistent with the person's known desires and that are medically reasonable and appropriate. A person can, but is not req living will. A person may write and use a living will without writing a health care power of attorney or may attach a living will to the person's health care power of attorney. If a person has a healdecisions to the same extent and under the same conditions as prescribed in section 36-3205. 36-3262. Sample living will Any writing that meets the requirements of this article may be used to create aection 36-3221. C. A health care provider who makes good faith health care decisions based on the provisions of an apparently genuine living will is immune from criminal and civil liability for those care power of attorney or to disqualify a surrogate. B. If the living will is not part of a health care power of attorney, the person shall verify his living will in the same manner as prescribed by s written statement known as a living will to control the health care treatment decisions that can be made on that person's behalf. The person may use the living will as part of or instead of a health Instructions ­ Page 2 the principal's estate by will or by operation of law at the time that the power of attorney is executed. 36-3261. Living will; verification; liability A. An adult may prepare af a health care power of attorney is witnessed by only one person, that person may not be related to the principal by blood, marriage or adoption and may not be entitled to any part of Information & ed to make medical decisions on the principal's behalf. 2. A person directly involved with the provision of health care to the principal at the time the health care power of attorney is executed. D. Ipower of attorney expressed the person's wishes and that the person intended to adopt the power of attorney at that time. C. A notary or witness shall not be any of the following: 1. A person designatrson is physically unable to sign or mark a health care power of attorney, the notary or each witness shall verify on the document that the person directly indicated to the notary or witness that the ower of attorney, except as provided under subsection B, and that the person appeared to be of sound mind and free from duress at the time of execution of the health care power of attorney. B. If a pecare power of attorney. 3. Is notarized or is witnessed in writing by at least one adult who affirms that the notary or witness was present when the person dated and signed or marked the health care prly indicates that the person intends to create a health care power of attorney. 2. Except as provided under subsection B, is dated and signed or marked by the person who is the subject of the health dult individuals to make health care decisions on that person's behalf by executing a written health care power of attorney that meets all of the following requirements: 1. Contains language that clea221. Health care power of attorney; scope; requirements; limitations (Note: These requirements also apply to living wills) A. A person who is an adult may designate another adult individual or other aPublic Health and Safety; Chapter 32; Article 5 of the Arizona Revised Statutes. For your convenience, we have included useful excerpts from the Arizona Revised Statutes relating to Living Wills. 36-3Information and Instructions Arizona Living Will This package contains (1) Information and Instruction for Arizona Living Will; (2) Arizona Living Will This Arizona Living Will is based on Title 36 - Arizona