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Arkansas ______________________ -2- ___________ Address: ______________________________________ _____________________________________________ (Witness Signature) Print Name: ___________________________________ Address: ________________ Code: ___________________________ The declarant voluntarily signed this writing in my presence. _____________________________________________ (Witness Signature) Print Name: ________________________ Name: ____________________________________________________________________ Address: __________________________________________________________________ -1- ______________________________________ Ziplife-sustaining treatment should be withheld or withdrawn. Signed this _________________ day of ____________________________, 20___ __________________________________________ (Declarant's Signature)f dying and is not necessary to my comfort or to alleviate pain ______________ follow the instructions of ___________________________________, whom I appoint as my Health Care Proxy to decide whether sician, pursuant to the Arkansas Rights of the Terminally Ill or Permanently Unconscious Act, to (select and initial one) ______________ withhold or withdraw treatment that only prolongs the process o______________, whom I appoint as my Health Care Proxy to decide whether life-sustaining treatment should be withheld or withdrawn. If I should become permanently unconscious I direct my attending phy_________ withhold 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 _____________________make decisions regarding my medical treatment, I direct my attending physician, pursuant to the Arkansas Rights of the Terminally Ill or Permanently Unconscious Act, to (select and initial one): _____f Use found at findlegalforms.com Living Will DECLARATION If I should have an incurable or irreversible condition that will cause my death within a relatively short time, and I am no longer able to nning matters. Any 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 oou and should not 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 plampleteness. [_]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 yical record. [_] 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 coeans if doing so would require the insertion of any apparatus into the patient's body. (b) The attending physician or other health care provider shall make the revocation a part of the declarant's medation, or both, shall be honored. (B) Unless the use of artificial means is specifically requested, a patient's request for nutrition or hydration, or both, shall not be honored by use of artificial mstructions ­ Page 2 communication to the attending physician or other health care provider by the declarant or a witness to the revocation. (2)(A) The wishes of a patient who requests nutrition, hydrion. (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 revocation is effective upon Information & Ins operative, the attending physician and other health care providers shall act in accordance with its provisions or comply with the transfer provisions of § 20-17207. 20-17-204. Revocation of declaratnsultation either to be in a terminal condition and no longer able to make decisions regarding administration of life-sustaining treatment or to be permanently unconscious. When the declaration becomeeclaration operative. A declaration becomes operative when (i) it is communicated to the attending physician and (ii) the declarant is determined by the attending physician and another physician in coconsultation with the attending physician, shall have the authority to make treatment decisions for the patient including the withholding or withdrawal of life-sustaining procedures. 20-17-203. When d 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 patient, the patient's health care proxy, in 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 furnished a copy of the declaration shall make it aal of life-sustaining treatment. The declaration must be signed by the declarant, or another at the declarant's direction, and witnessed by two (2) individuals. (b) A declaration may, but need not, bearation 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 declaration governing the withholding or withdraw20 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 Statutes relating to Living Wills. 20-17-202. DeclInformation and Instructions Arkansas Living Will This package contains (1) Information and Instruction for Arkansas Living Will; (2) Arkansas Living Will. This Arkansas Living Will is based on Title Arkansas