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Arkansas : ___________________________________ Address: ______________________________________ -2- ______ (Witness Signature) Print Name: ___________________________________ Address: ______________________________________ _____________________________________________ (Witness Signature) Print Name_____________ -1- ______________________________________ Zip Code: ___________________________ The declarant voluntarily signed this writing in my presence. _____________________________________________________________________________ (Declarant's Signature) Name: ____________________________________________________________________ Address: ________________________________________________________, whom I appoint as my Health Care Proxy to decide whether life-sustaining treatment should be withheld or withdrawn. Signed this _________________ day of ____________________________, 20___ ____ithhold or withdraw treatment that only prolongs the process of dying and is not necessary to my comfort or to alleviate pain ______________ follow the instructions of ________________________________ould become permanently unconscious I direct my attending physician, pursuant to the Arkansas Rights of the Terminally Ill or Permanently Unconscious Act, to (select and initial one) ______________ w___________ follow the instructions of ___________________________________, whom I appoint as my Health Care Proxy to decide whether life-sustaining treatment should be withheld or withdrawn. If I shanently Unconscious Act, to (select and initial one): ______________ withhold or withdraw treatment that only prolongs the process of dying and is not necessary to my comfort or to alleviate pain ___within a relatively short time, and I am no longer able to make decisions regarding my medical treatment, I direct my attending physician, pursuant to the Arkansas Rights of the Terminally Ill or Permse of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Living Will DECLARATION If I should have an incurable or irreversible condition that will cause my death attorney is always recommended when dealing with estate planning matters. Any possible tax consequences arising out of this document should be discussed with a tax professional. [_] The purchase and uto 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 particular situation. Advice from a local 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. Laws vary from time to time and from state er shall make the revocation a part of the declarant's medical record. [_] These forms are provided "as is" and no implied or express warranties have been made or are provided as to their suitabilitytion, or both, shall not be honored by use of artificial means if doing so would require the insertion of any apparatus into the patient's body. (b) The attending physician or other health care provid2)(A) The wishes of a patient who requests nutrition, hydration, or both, shall be honored. (B) Unless the use of artificial means is specifically requested, a patient's request for nutrition or hydrarevocation is effective upon Living Will Information & Instructions ­ Page 2 communication to the attending physician or other health care provider by the declarant or a witness to the revocation. (§ 20-17207. 20-17-204. Revocation of declaration. (a)(1) A declaration may be revoked at any time and in any manner by the declarant without regard to the declarant's mental or physical condition. A ntly unconscious. When the declaration becomes operative, the attending physician and other health care providers shall act in accordance with its provisions or comply with the transfer provisions of tending physician and another physician in consultation either to be in a terminal condition and no longer able to make decisions regarding administration of life-sustaining treatment or to be permaneife-sustaining procedures. 20-17-203. When declaration operative. A declaration becomes operative when (i) it is communicated to the attending physician and (ii) the declarant is determined by the atatient, the patient's health care proxy, in consultation with the attending physician, shall have the authority to make treatment decisions for the patient including the withholding or withdrawal of led a copy of the declaration shall make it a part of the declarant's medical record and, if unwilling to comply with the declaration, promptly so advise the declarant. (e) In the case of a qualified pals. (b) A declaration may, but need not, be in the following form in the case where the patient has a terminal condition. (see form below) (d) A physician or other health care provider who is furnishration governing the withholding or withdrawal of life-sustaining treatment. The declaration must be signed by the declarant, or another at the declarant's direction, and witnessed by two (2) individues relating to Living Wills. 20-17-202. Declaration relating to use of life-sustaining treatment. (a) An individual of sound mind and eighteen (18) or more years of age may execute at any time a declaThis Arkansas Living Will is based on Title 20 Chapter 17 Subchapter 2 Section 20-17-201 et. Seq. of the Arkansas Codes. For your convenience, we have included useful excerpts from the Arkansas Statutss: ______________________________________ Information and Instructions Arkansas Living Will This package contains (1) Information and Instruction for Arkansas Living Will; (2) Arkansas Living Will. _______________________________ Address: ______________________________________ _____________________________________________ (Witness Signature) Print Name: ___________________________________ Addreingly and free from duress. He or she signed (or asked another to sign for him or her) this document in my presence. _____________________________________________ (Witness Signature) Print Name: ____________________________________ Statement by Witnesses (must be 18 or older) I declare that the person who signed this document appeared to execute the durable power of attorney for health care willcare decisions. Signed this _________ day of ________________________ (month), 20____.(year) Signature____________________________________________________________ Address ____________________________ain, diagnose, treat, or provide for my physical or mental health or personal care. This Durable Power of Attorney for Health Care shall take effect in the event I become unable to make my own health or attorney- in-fact). My health care agent and any alternate health care agent shall have the authority to make all health care decisions regarding any care, treatment, service, or procedure to maintame of successor attorney- in-fact) _______________________________________________ (address of successor attorney- in- fact) _____________________________________________ (telephone number of successt I state otherwise. In the event the person I appoint is unable, unwilling or unavailable to act as my attorney- in- fact, I hereby appoint: _______________________________________________________ (n_______________________________________________________ ( home address and telephone number of agent) as my health care agent to make any and all health care decisions for me, except to the extent thacom -2- Power of Attorney for Health Care I, ________________________________________________________, (name) hereby appoint: __________________________________________________________ (name) at ___x 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 findlegalforms.document you should have an attorney review it to make sure it fits your particular situation. You should also consult an attorney whenever a document is negotiated with another party. Any possible taLaws 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 without consulting with an attorney first. Before using or signing this ade 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. suicide, or any action or course of action that violates the criminal laws of this state or of the United States. [_] These forms are provided "as is" and no implied or express warranties have been min this section shall be construed to affect in any way the provisions of § 28-1-101 et seq. (g) Nothing in this section shall be construed as authorizing or encouraging euthanasia, assisted suicide, under the foregoing act. (f) This section is wholly independent of the provisions of § 28-1-101 et seq. relating to wills, trusts, fiduciary relationships, and administration of estates, and nothing ision of the Arkansas Rights of the Terminally Ill and Permanently Unconscious Act, § 20-17-201 et seq. The powers of a health care agent may be combined with a declaration made by a qualified patienty act of an agent prior to July 1, 1999, or affect any claim, right, or remedy that accrued prior to July 1, 1999. Nothing contained herein shall be interpreted or construed to alter or amend any proved under a power of attorney for health care shall take precedence over any person listed in § 20-9-602. (e) This section does not in any way affect or invalidate any health care agency executed or anpal and in the principal's presence; and -1- (C) Attested to by and subscribed in the presence of two (2) or more competent witnesses who are at least eighteen (18) years of age. (3) An agent appointof attorney for health care. Such power of attorney may be durable. (2) The health care agency shall be: (A) In writing; (B) Signed by the principal or by someone acting at the direction of the princi§ 20-17-201 et seq. However, a power of attorney for health care may contain the declaration set forth in § 20-17-202 relating to such life-sustaining treatments. (d) (1) A person may execute a power ain, diagnose, treat, or provide for the patient's physical or mental health or personal care. (2) The term "health care" shall not include decisions concerning life-sustaining treatment set forth in e principal will be effective to the same extent as though made by the principal. (c) (1) For purposes of this section, the term "health care" means any care, treatment, service, or procedure to maintment may be denied unless the individua l, as principal, can delegate the decision- making power to a trusted agent and be sure that the agent's power to make personal and health care decisions for thbly recognizes the right of the individual to control all aspects of his or her personal care and medical treatment. However, if the individual becomes incapacitated, his or her right to control treat Health Care Form. 20-13-104. Durable power of attorney for health care. (a) This section shall be known and may be cited as the "Durable Power of Attorney for Health Care Act". (b) The General Assemy for Health Care is based on Title 20 Chapter 13 Section 20-13104 of the Arkansas Statutes. The following are useful excerpts from the Arkansas Statutes relating to the Arkansas Power of Attorney foror Health Care This package contains (1) Information and Instruction for Arkansas Power of Attorney for Health Care; (2) Arkansas Power of Attorney for Health Care Form. This Arkansas Power of Attorne with a tax professiona l. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Information and Instructions Arkansas Power of Attorney f your particular 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 discussedice. 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 without consulting an attorney first to make sure it fitseen made 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 advHealth 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 bArkansas Advance Health Care Directive This package contains both a Arkansas Power of Attorney for Health Care and a Arkansas Living Will. Together these forms are also sometimes known as an Advance Arkansas