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California nd official seal. Signature __________________________________ (Seal) -6- lf of which the person(s) acted, executed the instrument I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct WITNESS my hand aent and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon beha _____________________________ _______________________________________, who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrumCalifornia County of ________________________ ) ) ss ) On __________ before me, ______________________________________________________ (here insert name and title of the officer), personally appearedature: ___________________________________ Name: ___________________________________ City: __________________________________ State: ___________________________________ Notary Acknowledgment State of ipal Witness Signature: ___________________________________ Name: ___________________________________ City: __________________________________ State: ___________________________________ Witness Sign of Attorney at any time by providing written notice to my Agent. Signed on ________________ (date), at _______________________ (city), California. ________________________________ Signature of Princ However, Agent will be liable for breach of fiduciary duty, failure to act in good faith and/or willful misconduct, while acting under the authority of this Power of Attorney. I may revoke this Power good faith on the authority of this document, without notice of such termination, shall be held harmless. -5- Agent shall not be liable for losses resulting from judgment errors made in good faith. third party for any claims that arise against the third party because of reliance on this power of attorney. If this Durable Power of Attorney is terminated by operation of law, any person relying in copy of this document may act under it. Revocation of the power of attorney is not effective as to a third party until the third party has actual knowledge of the revocation. I agree to indemnify thewnership with respect to any life insurance policies I may own on the life of my Agent; and/or (c) my assets to be subject to a general power of appointment by my Agent. Any third party who receives a on this document. The powers granted to my Agent by this power-of-attorney are limited to the extent necessary to prevent (a) my income to be taxable to my Agent; (b) my Agent to have any rights or onot be affected by any partial invalidity. No person needs to inquire as to the reasons for the use or issuance of this power-ofattorney or as to the disposition of any proceeds paid to my Agent based If any part of this document is held to be invalid, illegal or unenforceable under applicable law, then the remaining unaffected parts of the document shall still remain in full force and effect and d as broadly as a General Power of Attorney. The listing of specific terms, rights, acts or powers are not intended to restrict or limit the definition or scope of powers granted herein in any manner.orized personal representative or fiduciary acting on my behalf, my Agent shall provide an accounting for all funds handled and all acts performed as my Agent. This Power of Attorney shall be construecarrying out any provision of this Power of Attorney. If desired, my Agent shall also be entitled to reasonable compensation for any services provided as my Agent If so requested by myself or any authanage my financial resources and affairs properly, as certified in writing by a licensed medical doctor. My Agent shall be entitled to reimbursement of all reasonable expenses incurred as a result of as provided by any applicable statute. As used herein, "disability" or "incapacity" shall mean a lack of capacity to receive and evaluate information effectively, to communicate decisions, and/or to m this document shall remain in full force and effect thereafter until my death. This Power of Attorney shall not terminate on my subsequent disability, incapacity or lack of mental competence, except Attorney and all rights and powers therein shall become effective upon my subsequent disability or incapacity as certified in writing by a licensed medical doctor. The rights, powers, and authority ofver, Agent may not disclaim assets, to -4- which I would be entitled, if the result is that the disclaimed assets pass directly or indirectly to my Agent or my Agent's estate. This Durable Power of disclaim any interest (subject to other provisions of this document), which might be transferred or distributed to me from any other person, estate, trust, or other entity, as may be appropriate. Howeexcluding those whom I am legally obligated to support. 16. To transfer any of my assets to the trustee of any revocable trust created by me, if such trust exists at the time of such transfer. 17. To creditors, or the creditors of my Agent's estate, or (c) use any of my assets to discharge any of my Agent's legal obligations, including any obligations of support which my Agent may owe to others, ctly, to my Agent, my Agent's estate, my Agent's creditors, or the creditors of my Agent's estate, (b) exercise any powers of appointment I may hold in favor of my Agent, my Agent's estate, my Agent's end of each calendar year. However, my Agent may not, unless specifically authorized by this document, (a) gift, appoint, assign or designate any of my assets, interests or rights, directly or indirefederal gift tax annual exclusion, shall not exceed in value the federal gift tax annual exclusion amount in any one calendar year, and this annual right shall be non-cumulative and shall lapse at they or parent, guardian or close friend of the minor or pursuant to the Uniform Gifts to Minors Act or the Uniform Transfers To Minors Act. Any gifts made shall be limited to gifts that qualify for the rd to whether such gifts are a part of my estate planning or otherwise, and if necessary, to file any state and federal gift tax returns and documents. Gifts to minors may be made to the minor directle, compromise or settle any matter with such agency. 15. To make gifts and charitable contributions of my real, personal, tangible or intangible property, to such persons or organizations without regar other income and tax returns and necessary and/or related documents; to obtain or provide information to and from any agency, including governmental agencies, relating to tax matters and to negotiatstate agents. 14. To prepare, or cause to be prepared, sign, and/or file any documents with any federal, state, local or other governmental body, including, but not limited to, federal, state, local ot in, in the future. 13. To employ any professional and/or business assistance as may be appropriate, including but not limited to, attorneys, accountants, investment professionals, brokers and real espect to stocks, bonds, debentures, commodities, options or any other investments. 12. To maintain and/or operate any business that I currently own or have an interest in or may own or have an interesnction with any other person, including access to their contents, and to examine, remove, keep or otherwise dispose of the contents. 11. To exercise any and all rights, including proxy rights, with reity, or draft of the United States of America, including U.S. Treasury Securities. -3- 10. To have access to any safe deposit box, vault or other storage area owned or leased by me alone or in conju certificates, cashier checks, cash or vouchers payable to me by any person, firm, corporation or political entity; to perform any act necessary to deposit, negotiate, sell or transfer any note, securccounts, including, but not limited to, making deposits and withdrawals, negotiating or endorsing any checks or other instruments, obtaining bank statements, passbooks, drafts, warrants, money orders,nts, brokerage accounts, retirement plan accounts, and other similar accounts with financial institutions; to conduct any business with any banking or financial institution with respect to any of my ase of receiving Social Security benefits. 9. To open, maintain and/or close bank accounts, including, but not limited to, checking accounts, savings accounts, certificates of deposit, investment accou with governmental benefits (including but not limited to, medical, military and social security benefits), and to appoint anyone, including my Agent, to act as my "Representative Payee" for the purpogram including, but not limited to, Social Security and Medicare; to prepare applications, provide information, and perform any other reasonable request by any government or its agencies in connectiones. 8. To receive, deposit, hold, demand, deal with and/or sue to recover all payments I receive from any annuity, pension, retirement benefits, retirement plans, insurance benefits and government pro with insurance and annuity contracts, insurance policies, including life insurance upon my life or the life of any other appropriate person and to make any elections and disclaimers under such polici; and the right to ask for, demand, sue for, collect, recover and receive all monies which may become due and owing to me by reason of such transaction. 7. To apply for, purchase, maintain and/or dealment, instrument or deed for such transactions. This includes the right to sell or encumber any homestead that I now own or may own in the future; the right to remove tenants and to recover possessionoper) deal with all, any part or any interest in any real or personal property or asset whatsoever, tangible or intangible (now owned or acquired in the future by me) and to execute any necessary docuest, to have, or use. 6. To maintain, manage, insure, lease, rent, sell, mortgage, improve, repair, exchange, invest, reinvest and in any other manner (on such terms and at prices my Agent may deem prts of title and demands whatsoever, whether agreed to or disputed, now due or due in the future, owned by, due, owing payable, or belonging to, me or in which I have or may hereafter acquire any interst any and all sums of money, accounts, debts, bonds, commercial papers, checks, drafts, causes of action, bequests, deposits, notes, interests, dividends, certificates of deposit, any and all documenect any amount or debt owed to me. 4. To adjust, compromise and settle any claim, against me or asserted on my behalf against any other person or entity. -2- 5. To receive, hold, possess and/or inve other debts and obligations and such other instruments in writing of whatever kind and nature as may be. 3. To request, ask, demand, sue and take any and all legal steps necessary to recover and collugh banks, savings and loan, brokers, mutual fund companies or other institutions, proofs of loss, evidences of debts, releases, and satisfaction of mortgages, lien, judgments, security agreements andpts, title documents, checks, drafts, letters of credit, stock certificates, proxies, warrants, commercial papers, withdrawal and deposit slips, certificates of deposit of, or investments with or throd to applications, assignments, bills of sale or lading, bonds, contracts, covenants, conveyances, deeds, options, trust deeds, security agreements, leases, mortgages, notes, insurance policies, recei2. To enter into binding contracts on my behalf and to sign, endorse and execute any written agreement and document necessary to enter into any such contract and/or agreement, including but not limitented. My Agent's powers and authority shall include, but not be limited to: 1. To conduct, engage in, and transact any and all lawful business of whatever kind or nature, on my behalf and in my name. resent. I hereby ratify and confirm all acts that my Agent, or my Agent's substitute or substitutes, shall lawfully do or cause to be done by virtue of this power of attorney and the rights hereby gray later acquire in connection with or relating to any person, item, transaction, thing, business, property, real or personal, tangible or intangible, or matter whatsoever as I could do if personally pcessary, to serve with the same powers, rights and discretions. My Agent shall have full power and authority to perform any act, power, duty, legal right or obligation whatsoever that I now have or maable to serve for any reason, I appoint _____________________________________ maintaining an address at: _____________________________________________________ as my alternate or successor Agent, as ne_ ("Agent") maintaining an address at: _____________________________________________________ my true and lawful attorney-in-fact for me and in my name, and in my behalf. If the above named Agent is unENTS: I, ____________________________________ ("Principal") maintaining an address at _______________________________________________ do hereby make and appoint _______________________________________ny provision of it, then you should obtain the assistance of an attorney or other qualified person. -1- CALIFORNIA DURABLE POWER OF ATTORNEY Effective upon Disability KNOW ALL PERSONS BY THESE PRESy will give your agent the right to deal with property that you now have or might acquire in the future. The power of attorney is important to you. If you do not understand the power of attorney, or ay that may affect real property should be acknowledged before a notary public so that it may easily be recorded. You should read this power of attorney carefully. When effective, this power of attornenesses. If it is signed by two witnesses, they must witness either (1) the signing of the power of attorney or (2) the principal's signing or acknowledgment of his or her signature. A power of attorneright to revoke or terminate this power of attorney at any time, so long as you are competent. This power of attorney must be dated and must be acknowledged before a notary public or signed by two witthis power of attorney. You can amend or change this power of attorney only by executing a new power of attorney or by executing an amendment through the same formalities as an original. You have the wers you give your agent in this power of attorney will continue to exist even if you can no longer make your own decisions respecting the management of your property, unless you provide otherwise in gent will continue to exist for your entire lifetime, unless you state that the power of attorney will last for a shorter period of time or unless you otherwise terminate the power of attorney. The porney. Your agent will have the right to receive reasonable payment for services provided under this power of attorney unless you provide otherwise in this power of attorney. The powers you give your amanage, dispose of, sell and convey your real and personal property, and to use your property as security if your agent borrows money on your behalf, unless you provide otherwise in this power of attoof attorney, you should know these important facts: Your agent (attorney-in-fact) has no duty to act unless you and your agent agree otherwise in writing. This document gives your agent the powers to of Attorney Warning A power of attorney is an important legal document. By signing the power of attorney, you are authorizing another person to act for you, the principal. Before you sign this power information that is not state specific. Whenever appropriate, the instructions included with the forms packages offered for sale, generally include state specific instructions. -2- California Powercessary, if the Agent will deal with any real estate in Florida. Please note that this information is not intended as and is not a substitute for legal advice. Furthermore, this information is generalttorney to be recorded as a public record, if necessary. Although, some states don't require that a Durable Power of Attorney be witnessed, it is always a very good idea to do so. Two witnesses are ne the Agent will be dealing with any real property. Notarization will make it more difficult for any third party to challenge the validity of the Power of Attorney and will allow the Durable Power of Aned, in the event the original Agent is unable to serve or continue to serve as the Agent. A Durable Power of Attorney should always be notarized, even if your state does not require it, especially ifat any time. Since this Durable Power of Attorney takes effect only after the Principal becomes disabled or incompetent, an alternate Agent can be designated, at the time this Power of Attorney is sigpal. This is especially important if the Principal is incapacitated when the Power of Attorney goes into effect, or the Agent undertakes the acts. The Principal can revoke a Durable Power of Attorney of Attorney is a "powerful" instrument and should be granted with care. Any action undertaken by the Agent, within the scope of the Power of Attorney document, will be legally binding upon the Princiused here to mean "lawyer". The person acting as the attorney-in-fact for the Principal does not need to be a lawyer. Almost anyone can be appointed an attorney-in-fact by a power of attorney. A Powern his or her behalf, even if the Principal later becomes incapacitated. This particular Form becomes effective upon the disability or incapacity of the Principal. Note that the word "attorney" is not isability A Durable Power of Attorney allows a natural "mentally competent " person (called the "Principal" or "Principal") to authorize someone else (called the "Agent" or "AttorneyIn-Fact") to act oocument with another party. The purchase and use of these forms, is subject to the Disclaimers and Terms of Use found at findlegalforms.com -1- Information Durable Power of Attorney Effective upon Dubstitute for legal advice. These forms should only be a starting point for you and should not be used without consulting with an attorney first. An Attorney should be consulted before negotiating a de as Agent is unable to serve or continue to serve as the Agent. This section can be removed, deleted (and initialed) or the words "no one" can be entered. These forms are not intended and are not a s sweeping, as the Agent has the power to handle business and legal matters on the Principal's behalf. This document offers the option of nominating an alternate Agent in the event that the first choicthe Agent (or attorney-in-fact) as to the tasks the Agent should complete. The Grantor should also be very careful in the selection of the Agent. The powers granted by this document are very broad andd not be a witness. The Principal should keep the original document, as well as a copy. The Agent should have access to the original document as needed. The Principal should be careful in instructing 1) the signing of the power of attorney or (2) the principal's signing or acknowledgment of his or her signature. Generally, anyone related by blood or marriage to the Principal, Agent or Notary shoulecord, if necessary. In California, the power of attorney must be dated and must be acknowledged before a notary public or signed by two witnesses. If two witnesses sign it, they must witness either (e Principal. The Principal (i.e. the person granting the Power of Attorney) should sign the document before a Notary. Notarization will allow the Durable Power of Attorney to be recorded as a public r Information for Durable Power of Attorney Effective upon Disability; (3) Durable Power of Attorney Effective upon Disability This Durable Power of Attorney becomes effective upon the Disability of thInstructions & Checklist California Durable Power of Attorney Effective upon Disability This package contains (1) Instructions & Checklist for Durable Power of Attorney Effective upon Disability; (2) CaliforniaCalifornia NALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct WITNESS my hand and official seal. Signature __________________________________ (Seal) eir authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument I certify under PE proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/the me, ______________________________________________________ (here insert name and title of the officer), personally appeared _____________________________ _______________________________________, who________ Names of institutions/individuals who have been provided a copy of this revocation: Notary Acknowledgment State of California County of ________________________ ) ) ss ) On __________ befor______ State:_________________________ Witness Signature:__________________ Date: ___________________________ Name: ___________________________ City: _________________________ State:_________________ ___________________ (date). _____________________________ Principal Witness Signature:__________________ Date: ___________________________ Name: ___________________________ City: ___________________ artificial life sustaining procedures is revoked and withdrawn and this document provides notice of such revocation. IN WITNESS WHEREOF, I have signed this Health Care Power of Attorney Revocation on______________________________ (title of document(s)) dated __________________ and all power and authority granted thereby including powers for making health care decisions on my behalf and concerningRevocation I, ___________________________________ (Principal) maintaining an address at __________________________________________________ (address of Principal), hereby revoke my ____________________ion that is not state specific. Whenever appropriate, the instructions included with the forms packages offered for sale, generally include state specific instructions. Health Care Power of Attorney revoked. This revocation becomes effective immediately. Please note that this information is not intended as and is not a substitute for legal advice. Furthermore, this information is general informate Power of Attorney Revocation is used by the Grantor to give notice that a previously granted Health Care Power of Attorney (sometimes referred to as a Living Will or Health Care Directive) has been alth Care Power of Attorney Revocation If the Grantor of a Health Care Power of Attorney decides to revoke the document, it is almost always required that the revocation be in writing. The Health Carfor you and should not be used without consulting with an attorney first. The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Information Hetify both. These forms are not intended and are not a substitute for legal advice. Laws are different from state to state and may change from time to time. These forms should only be a starting point e revocation document. If more than one document is being revoked, then each document needs to be identified i.e. if you are revoking a Health Care Power of Attorney and a Living Will, be sure to idenpies of the Health Care Power of Attorney so as to avoid any questions about the revocation or its effectiveness. The exact full title of the document(s) that you are revoking should be inserted in thon. In the event the original power of attorney was filed publicly (i.e. recorded), then the notice of revocation should also be filed publicly, in the same manner. The Principal should destroy any coceived a copy of the original Power of Attorney or who may have dealt with the Agent acting on behalf of the Principal. It is a good idea to keep a record of anyone who was sent a copy of the revocatio the Principal, the Agent or the Notary should not be a witness. The Principal should keep a copy of the revocation in his/her files. Copies of the revocation should be sent to anyone who may have reough not always required, it is always a good idea to also have two witnesses sign the Revocation of Power of Attorney. The witnesses should be adults. Generally, anyone related by blood or marriage tified mail receipt, delivery receipt etc..). Any health care providers need to be given a copy of the Revocation as well and copies of the revocation should be kept in any relevant medical files. Alth show that it was the Grantor's intent to revoke the Power of Attorney. If possible, the Principal should keep a copy of any document showing that the Agent received the original revocation (i.e. certd. Notarization is also necessary to record the revocation. This revocation becomes effective immediately. The original or a copy of the revocation must be given to the Agent (i.e. Attorney-inFact) tohe Health Care Power of Attorney Revocation before a Notary even if it is not required. Notarization will also help to ensure that the revocation is effective and support its authenticity if challengeer of Attorney Revocation (3) Health Care Power of Attorney Revocation The Principal (i.e. the person granting the Health Care Power of Attorney Revocation; sometimes called the Grantor) should sign tInstructions & Checklist Health Care Power of Attorney Revocation This package includes (1) Checklist & Instructions for Health Care Power of Attorney Revocation (2) Information about Health Care Pow CaliforniaCalifornia __________________________________ 4 Initials ______ ________________________ Print your name: ___________________________________ Address: __________________________________________ City: _____________________________________________ State: ___________erving as a witness as required by Section 4675 of the Probate Code. Date: _____________________________________________ Name: ____________________________________________ Sign your name _____________F PATIENT ADVOCATE OR OMBUDSMAN I declare under penalty of perjury under the laws of California that I am a patient advocate or ombudsman as designated by the State Department of Aging and that I am sre and supportive care to patients whose primary need is for availability of skilled nursing care on an extended basis. The patient advocate or ombudsman must sign the following statement: STATEMENT OESS REQUIREMENT (5.1) The following statement is required only if you are a patient in a skilled nursing facility--a health care facility that provides the following basic services: skilled nursing car her death under a will now existing or by operation of law. Signature of Witness: ___________________________________ Signature of Witness: ___________________________________ PART 5 - SPECIAL WITNted to the individual executing this advance health care directive by blood, marriage, or adoption, and to the best of my knowledge, I am not entitled to any part of the individual's estate upon his oITIONAL STATEMENT OF WITNESSES: At least one of the above witnesses must also sign the following declaration: I further declare under penalty of perjury under the laws of California that I am not rela____________________________ Address: ___________________________________________ Signature of Witness: _________________________________ Date: ______________________________________________ (4.4) ADD_______________________________ Signature of Witness: _________________________________ Date: ______________________________________________ 3 Initials ______ SECOND WITNESS Name: _________________l care facility for the elderly, nor an employee of an operator of a residential care facility for the elderly. FIRST WITNESS Name: _____________________________________________ Address: ____________th care provider, an employee of the individual's health care provider, the operator of a community care facility, an employee of an operator of a community care facility, the operator of a residentiaividual appears to be of sound mind and under no duress, fraud, or undue influence, (4) that I am not a person appointed as agent by this advance directive, and (5) that I am not the individual's healpersonally known to me, or that the individual's identity was proven to me by convincing evidence (2) that the individual signed or acknowledged this advance directive in my presence, (3) that the ind________________ (4.3) STATEMENT OF WITNESSES: I declare under penalty of perjury under the laws of California (1) that the individual who signed or acknowledged this advance health care directive is _ Print your name ______________________________________ Address ____________________________________________ City _______________________________________________ State _______________________________f this form has the same effect as the original. (4.2) SIGNATURE: Sign and date the form here: Date: ______________________________________________ Sign your name ____________________________________________________ City, State, Zip Code: ___________________________________________________ Phone: _______________________________________________________________ PART 4 (4.1) EFFECT OF COPY: A copy ophysician, I designate the following physician as my primary physician: Name of physician: _____________________________________________________ Address: ________________________________________________________ Phone: _______________________________________________________________ OPTIONAL: If the physician I have designated above is not willing, able, or reasonably available to act as my primary ___________________________________________ Address: _____________________________________________________________ 2 Initials ______ City, State, Zip Code: _________________________________________t want): (1) Transplant (2) Therapy (3) Research (4) Education PART 3 - PRIMARY PHYSICIAN - (OPTIONAL) (3.1) I designate the following physician as my primary physician: Name of physician: __________ssues, or parts only: _________________________ _______________________________________________________________________ (c) My gift is for the following purposes (strike any of the following you do nosheets if needed.) PART 2 - DONATION OF ORGANS AT DEATH - (OPTIONAL) (2.1) Upon my death (mark applicable box): (a) I give any needed organs, tissues, or parts, OR (b) I give the following organs, tibove, you may do so here.) I direct that: ______________________________________________________________________ ______________________________________________________________________ (Add additional Add additional sheets if needed.) (1.3) OTHER WISHES: (If you do not agree with any of the optional choices above and wish to write your own, or if you wish to add to the instructions you have given at be provided at all times, even if it hastens my death: ______________________________________________________________________ ______________________________________________________________________ (s possible within the limits of generally accepted health care standards. (1.2) RELIEF FROM PAIN: Except as I state in the following space, I direct that treatment for alleviation of pain or discomfort regain consciousness, or (3) the likely risks and burdens of treatment would outweigh the expected benefits, OR (b) Choice To Prolong Life 1 Initials ______ I want my life to be prolonged as long a if (1) I have an incurable and irreversible condition that will result in my death within a relatively short time, (2) I become unconscious and, to a reasonable degree of medical certainty, I will noroviders and others involved in my care provide, withhold, or withdraw treatment in accordance with the choice I have marked below: (a) Choice Not To Prolong Life I do not want my life to be prolonged form at any time. PART 1 - INSTRUCTIONS FOR HEALTH CARE If you fill out this part of the form, you may strike any wording you do not want. (1.1) END-OF-LIFE DECISIONS: I direct that my health care p talk to the person you have named as agent to make sure that he or she understands your wishes and is willing to take the responsibility. You have the right to revoke this living will or replace thisompleted form to your physician, to any other health-care provider you may have, to any health-care institution at which you are receiving care and to any health-care agents you have named. You shouldr health care. After completing this form, sign and date the form at the end. The form must be signed by two qualified witnesses or acknowledged before a notary public. Give a copy of the signed and crt 2 of this form lets you express an intention to donate your bodily organs and tissues following your death. Part 3 of this form lets you designate a physician to have primary responsibility for youwithdrawal of treatment to keep you alive, as well as the provision of pain relief. Space is also provided for you to add to the choices you have made or for you to write out any additional wishes. Pas you give specific instructions about any aspect of your health care, whether or not you appoint an agent. Choices are provided for you to express your wishes regarding the provision, withholding or donation of organs and the designation of your primary physician. If you use this form, you may complete or modify all or any part of it. You are free to use a different form. Part 1 of this form letCALIFORNIA LIVING WILL (Based in part on California Probate Code Section 4701) You have the right to give instructions about your own health care. This form also lets you express your wishes regarding CaliforniaCalifornia 6 Initials ______ the laws of the State of California that the foregoing paragraph is true and correct WITNESS my hand and official seal. Signature __________________________________ (Seal) Source: findlegalforms.comy(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument I certify under PENALTY OF PERJURY underasis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacit______________________________________ (here insert name and title of the officer), personally appeared _____________________________ _______________________________________, who proved to me on the b__________________ State: _____________________________________________ Notary Acknowledgment State of California County of ________________________ ) ) ss ) On __________ before me, ________________________ Sign your name _____________________________________ Print your name: ___________________________________ Address: __________________________________________ City: ___________________________ Department of Aging and that I am serving as a witness as required by Section 4675 of the Probate Code. Date: _____________________________________________ Name: ____________________________________com 5 Initials ______ STATEMENT OF PATIENT ADVOCATE OR OMBUDSMAN I declare under penalty of perjury under the laws of California that I am a patient advocate or ombudsman as designated by the Statetive care to patients whose primary need is for availability of skilled nursing care on an extended basis. The patient advocate or ombudsman must sign the following statement: Source: findlegalforms.NT (5.1) The following statement is required only if you are a patient in a skilled nursing facility--a health care facility that provides the following basic services: skilled nursing care and supporder a will now existing or by operation of law. Signature of Witness: ___________________________________ Signature of Witness: ___________________________________ PART 5 - SPECIAL WITNESS REQUIREMEividual executing this advance health care directive by blood, marriage, or adoption, and to the best of my knowledge, I am not entitled to any part of the individual's estate upon his or her death unENT OF WITNESSES: At least one of the above witnesses must also sign the following declaration: I further declare under penalty of perjury under the laws of California that I am not related to the ind_____________ Address: ___________________________________________ Signature of Witness: _________________________________ Date: ______________________________________________ (4.4) ADDITIONAL STATEM____________________________________ Signature of Witness: _________________________________ Date: ______________________________________________ SECOND WITNESS Name: ________________________________ential care facility for the elderly, nor an employee of an operator of a residential care facility for the elderly. FIRST WITNESS Name: _____________________________________________ Address: _______ health care provider, an employee of the individual's health care provider, the operator of a community care facility, an employee of an operator of a community care facility, the operator of a residr no duress, fraud, or undue influence, (4) that I am not a person appointed as Source: findlegalforms.com 4 Initials ______ agent by this advance directive, and (5) that I am not the individual'sal's identity was proven to me by convincing evidence (2) that the individual signed or acknowledged this advance directive in my presence, (3) that the individual appears to be of sound mind and undeS: I declare under penalty of perjury under the laws of California (1) that the individual who signed or acknowledged this advance health care directive is personally known to me, or that the individu___________ Address ____________________________________________ City _______________________________________________ State _______________________________________________ (4.3) STATEMENT OF WITNESSEal. (4.2) SIGNATURE: Sign and date the form here: Date: ______________________________________________ Sign your name ______________________________________ Print your name ________________________________________________________________________ Phone: _______________________________________________________________ PART 4 (4.1) EFFECT OF COPY: A copy of this form has the same effect as the originn as my primary physician: Name of physician: _____________________________________________________ Address: _____________________________________________________________ City, State, Zip Code: __________________________________________ OPTIONAL: If the physician I have designated above is not willing, able, or reasonably available to act as my primary physician, I designate the following physicia___________________ Address: _____________________________________________________________ City, State, Zip Code: ___________________________________________________ Phone: ___________________________(2) Therapy (3) Research (4) Education PART 3 - PRIMARY PHYSICIAN - (OPTIONAL) (3.1) I designate the following physician as my primary physician: Name of physician: _______________________________________________________________________________ (c) My gift is for the following purposes (strike any of the following you do not want): Source: findlegalforms.com 3 Initials ______ (1) Transplant ) Upon my death (mark applicable box): (a) I give any needed organs, tissues, or parts, OR (b) I give the following organs, tissues, or parts only: _________________________ __________________________is not willing, able, or reasonably available to act as conservator, I nominate the alternate agents whom I have named, in the order designated. PART 2 - DONATION OF ORGANS AT DEATH - (OPTIONAL) (2.1 (Add additional sheets if needed.) (1.6) NOMINATION OF CONSERVATOR: If a conservator of my person needs to be appointed for me by a court, I nominate the agent designated in this form. If that agent __________________________________________________________ ______________________________________________________________________ ______________________________________________________________________AGENT'S POSTDEATH AUTHORITY: My agent is authorized to make anatomical gifts, authorize an autopsy, and direct disposition of my remains, except as I state here or in Part 2 of this form: ____________isions for me in accordance with what my agent determines to be in my best interest. In determining my best interest, my agent shall consider my personal values to the extent known to my agent. (1.5) attorney for health care, any instructions I give in Part 2 of this form, and my other wishes to the extent known to my agent. To the extent my wishes are unknown, my agent shall make health care decthis box my agent's authority to make health care decisions for me takes effect immediately. (1.4) AGENT'S OBLIGATION: My agent shall make health care decisions for me in accordance with this power ofTHORITY BECOMES EFFECTIVE: My agent's authority becomes effective when my primary physician determines that I am unable to make my own health care decisions unless I mark the following box. If I mark _______________________ Source: findlegalforms.com 2 Initials ______ ______________________________________________________________________ (Add additional sheets if needed.) (1.3) WHEN AGENT'S AUtion and all other forms of health care to keep me alive, except as I state here: ______________________________________________________________________ _______________________________________________________________________ (1.2) AGENT'S AUTHORITY: My agent is authorized to make all health care decisions for me, including decisions to provide, withhold, or withdraw artificial nutrition and hydra_______ Address: _____________________________________________________________ City, State, Zip Code: ___________________________________________________ Phone Home _____________________ Work: _______her is willing, able, or reasonably available to make a health care decision for me, I designate as my second alternate agent: Name of individual you choose as second alternate agent: ___________________________________________________________ Phone Home _____________________ Work: ______________________________ OPTIONAL: If I revoke the authority of my agent and first alternate agent or if neitt alternate agent: Name of individual you choose as alternate agent: ____________________________ Address: _____________________________________________________________ City, State, Zip Code: _______k: ______________________________ OPTIONAL: If I revoke my agent's authority or if my agent is not willing, able, or reasonably available to make a health care decision for me, I designate as my firs_________________ Address: _____________________________________________________________ City, State, Zip Code: ___________________________________________________ Phone Home _____________________ Wor ATTORNEY FOR HEALTH CARE (1.1) DESIGNATION OF AGENT: I designate the following individual as my agent to make health care decisions for me: Name of individual you choose as agent: ___________________e that he or she understands your wishes and is willing to take the responsibility. You have the right to revoke this advance health-care directive or replace this form at any time. PART 1 - POWER OFitution at which you are receiving care and to any health-care Source: findlegalforms.com 1 Initials ______ agents you have named. You should talk to the person you have named as agent to make sur two qualified witnesses or acknowledged before a notary public. Give a copy of the signed and completed form to your physician, to any other health-care provider you may have, to any health-care instdeath. Part 3 of this form lets you designate a physician to have primary responsibility for your health care. After completing this form, sign and date the form at the end. The form must be signed bycitation. (e) Make anatomical gifts, authorize an autopsy, and direct disposition of remains. Part 2 of this form lets you express an intention to donate your bodily organs and tissues following your l procedures, and programs of medication. (d) Direct the provision, withholding, or withdrawal of artificial nutrition and hydration and all other forms of health care, including cardiopulmonary resus procedure to maintain, diagnose or otherwise affect a physical or mental condition. (b) Select or discharge health-care providers and institutions. (c) Approve or disapprove diagnostic tests, surgica-care decisions that may have to be made. If you choose not to limit the authority of your agent, your agent will have the right to: (a) Consent or refuse to consent to any care, treatment, service ore all health-care decisions for you. This form has a place for you to limit the authority of your agent. You need not limit the authority of your agent if you wish to rely on your agent for all healtho you or is a coworker. Additionally, you should consult an attorney before designating your conservator as your agent.) Unless the form you sign limits the authority of your agent, your agent may makresidential care facility where you are receiving care, or your supervising health care provider or employee of the health care institution where you are receiving care, unless your agent is related tnate agent to act for you if your first choice is not willing, able or reasonably available to make decisions for you. (Your agent may not be an operator or employee of a community care facility or a are decisions for you if you become incapable of making your own decisions or if you want someone else to make those decisions for you now even though you are still capable. You may also name an alterete or modify all or any part of it. You are free to use a different form. Part 1 of this form is a Power of Attorney for Health Care. Part 1 lets you name another individual as agent to make health-cother person to make health-care decisions for you. It also lets you express your wishes regarding donation of organs and the designation of your primary physician. If you use this form, you may complode Section 4701) You have the right to give instructions about your own health care. You also have the right to name someone else to make health-care decisions for you. This form lets you nominate anchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Source: findlegalforms.com 4 POWER OF ATTORNEY FOR HEALTH CARE (Based on California Probate Cng this 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. The puradvice. 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 without consulting with an attorney first. Before using or signi information to the agent. Disclosure under this section is not a waiver of any privilege that may apply to the information disclosed. These forms are not intended and are not a substitute for legal person, including a business entity or government agency, with respect to matters covered by the power of attorney for health care. A person from whom information is requested shall disclose relevantor this purpose, and may also consult with and obtain information needed to carry out the agent's duties from the principal' s spouse, physician, attorney, a member of the principal's family, or otherhe principal becomes wholly or partially incapacitated, or if there is a question concerning the capacity of the principal, the agent may consult with a person previously designated by the principal fpal objects to the health care decision of the agent under a power of attorney, the matter shall be governed by the law that would apply if there were no power of attorney for health care. 4690. If tndlegalforms.com 3 4689. Nothing in this division authorizes an agent under a power of attorney for health care to make a health care decision if the principal objects to the decision. If the princie or participate in making health care decisions for the principal. 4688. Where this division does not provide a rule governing agents under powers of attorney, the law of agency applies. Source: fi the power of attorney. 4687. Nothing in this division affects any right the person designated as an agent under a power of attorney for health care may have, apart from the power of attorney, to makns for the principal. 4686. Unless the power of attorney for health care provides a time of termination, the authority of the agent is exercisable notwithstanding any lapse of time since execution of in the power of attorney who is known to the health care provider to be reasonably available and willing to make health care decisions has priority over any other person in making health care decisios best interest, the agent shall consider the principal's personal values to the extent known to the agent. 4685. Unless the power of attorney for health care provides otherwise, the agent designatedother wishes to the extent known to the agent. Otherwise, the agent shall make the decision in accordance with the agent's determination of the principal's best interest. In determining the principal'tion of remains under Section 7100 of the Health and Safety Code. 4684. An agent shall make a health care decision in accordance with the principal's individual health care instructions, if any, and hapter 3.5 (commencing with Section 7150) of Part 1 of Division 7 of the Health and Safety Code). (2) Authorizing an autopsy under Section 7113 of the Health and Safety Code. (3) Directing the disposie capacity to do so. (b) The agent may also make decisions that may be effective after the principal's death, including the following: (1) Making a disposition under the Uniform Anatomical Gift Act (Chealth care: (a) An agent designated in the power of attorney may make health care decisions for the principal to the same extent the principal could make health care decisions if the principal had thetermination that the principal lacks capacity, and ceases to be effective on a determination that the principal has recovered capacity. 4683. Subject to any limitations in the power of attorney for tection of third persons from liability. Source: findlegalforms.com 2 4682. Unless otherwise provided in a power of attorney for health care, the authority of an agent becomes effective only on a d (2) Operative dates of statutory enactments or amendments. (3) Formalities for execution of a power of attorney for health care. (4) Qualifications of witnesses. (5) Qualifications of agents. (6) Protatute specifically providing that it is not subject to limitation in the power of attorney or a statute concerning any of the following: (1) Statements required to be included in a power of attorney.ss statement in the power of attorney for health care or by providing an inconsistent rule in the power of attorney. (b) A power of attorney for health care may not limit either the application of a slly sufficient if it satisfies the requirements of Section 4673. 4681. (a) Except as provided in subdivision (b), the principal may limit the application of any provision of this division by an expreatient if the patient advocate or ombudsman believes that the representations provide a reasonable basis for determining the identity of the patient. 4680. A power of attorney for health care is legais a patient advocate or ombudsman may rely on the representations of the administrators or staff of the skilled nursing facility, or of family members, as convincing evidence of the identity of the ponmaking role, by virtue of the custodial nature of their care, so as to require special assurance that they are capable of willfully and voluntarily executing an advance directive. (b) A witness who or she is serving as a witness as required by this subdivision. It is the intent of this subdivision to recognize that some patients in skilled nursing facilities are insulated from a voluntary decisiany other applicable provision of law, signs the advance directive as a witness, either as one of two witnesses or in addition to notarization. The patient advocate or ombudsman shall declare that he advance health care directive is executed, the advance directive is not effective unless a patient advocate or ombudsman, as may be designated by the Department of Aging for this purpose pursuant to licable to witnesses do not apply to a notary public before whom an advance health care directive is acknowledged. 4675. (a) If an individual is a patient in a skilled nursing facility when a writtend, to the best of my knowledge, I am not entitled to any part of the individual's estate upon his or her death under a will now existing or by operation of law." (g) The provisions of this section apptance: "I further declare under penalty of perjury under the laws of California that I am not related to the individual executing this advance health care directive by blood, marriage, or adoption, anll existing when the advance directive is executed or by operation of law then existing. (f) The witness satisfying the requirement of subdivision (e) shall also sign the following declaration in subsndividual who is neither related to the patient by blood, marriage, or adoption, nor entitled to any portion of the patient's estate upon the Source: findlegalforms.com 1 patient's death under a wie facility, the operator of a residential care facility for the elderly, nor an employee of an operator of a residential care facility for the elderly." (e) At least one of the witnesses shall be an i (5) that I am not the individual's health care provider, an employee of the individual's health care provider, the operator of a community care facility, an employee of an operator of a community carrective in my presence, (3) that the individual appears to be of sound mind and under no duress, fraud, or undue influence, (4) that I am not a person appointed as agent by this advance directive, and this advance health care directive is personally known to me, or that the individual's identity was proven to me by convincing evidence, (2) that the individual signed or acknowledged this advance difor health care. (d) Each witness shall make the following declaration in substance: "I declare under penalty of perjury under the laws of California (1) that the individual who signed or acknowledgedoperator or an employee of a community care facility. (3) The operator or an employee of a residential care facility for the elderly. (4) The agent, where the advance directive is a power of attorney of the signature or the advance directive. (c) None of the following persons may act as a witness: (1) The patient's health care provider or an employee of the patient's health care provider. (2) The e satisfied: (a) The witnesses shall be adults. (b) Each witness signing the advance directive shall witness either the signing of the advance directive by the patient or the patient's acknowledgment esses who satisfy the requirements of Sections 4674 and 4675. 4674. If the written advance health care directive is signed by witnesses, as provided in Section 4673, the following requirements shall bpatient's name by another adult in the patient's presence and at the patient's direction. (c) The advance directive is either (1) acknowledged before a notary public or (2) signed by at least two witnufficient if all of the following requirements are satisfied: (a) The advance directive contains the date of its execution. (b) The advance directive is signed either (1) by the patient or (2) in the The following are useful excerpts from California Probate Code Sections 4673 to 4690, relating to the Power Of Attorney For Health Care Form. 4673. A written advance health care directive is legally sttorney For Health Care Form This California Durable Power Of Attorney For Health Care is based in part on the California Advance Health Care Directive (California Probate Code Section 4701 et. Seq.) Information California Durable Power Of Attorney For Health Care This package contains (1) Information about the California Durable Power Of Attorney For Health Care; (2) California Durable Power Of A CaliforniaCalifornia _________________ Name: _______________________________________________ Address: ____________________________________________ City: _______________________________________________ State: ______________________________: _______________________________________________ State: _______________________________________________ SECOND WITNESS: Date: __________________ Signature: ___________________________________________ITNESS: Date: __________________ Signature: ___________________________________________ Name: _______________________________________________ Address: ____________________________________________ Cityion and in the presence of the Donor and each other. The individual signing the Donation of Gift was directed to do so by the Donor and signed the document in his/her presence as well as ours. FIRST Wnd by two witnesses, all of whom have signed at the direction and in the presence of the donor and of each other, and state that it has been so signed.] Witness Statement: We have signed at the direct____________________ WITNESS FORM [An anatomical gift may be made only by a document of gift signed by the donor. If the donor cannot sign, the document of gift must be signed by another individual a_ Print your name: ______________________________________ Address: ____________________________________________ City: _______________________________________________ State: ___________________________n, surgeon, technician, or enucleator to carry out the appropriate procedures. SIGNATURE: (Sign and date the form here:) Date: __________________ Sign your name: _____________________________________the appropriate procedures. In the absence of a designation or if the designee is not available, the donee or other person authorized to accept the anatomical gift may employ or authorize any physiciaof the following you do not want): (1) Transplant (2) Therapy (3) Research (4) Education (Optional) I designate ___________________________________ as my particular physician or surgeon to carry out __ ________________________________________________________________________ ________________________________________________________________________ My gift is for the following purposes (strike any x): Give any needed organs, tissues, or parts, OR Give the following organs, tissues, or parts only: ____________________________ ______________________________________________________________________ for all serious legal matters. Anatomical Gift by Living Donor Pursuant to Uniform Anatomical Gift Act Upon my death, I ____________________________________ (the "Donor"), hereby (mark applicable boand on any theory of liability, whether in contract, strict liability, or tort (including negligence or otherwise) arising in any way out of the use of these materials. An attorney should be consultedntal, special, exemplary, or consequential damages (including, but not limited to, procurement of substitute goods or services; loss of use, data, or profits; or business interruption) however caused risk. In no event will: i) FindLegalForms, Inc, its agents, partners, or affiliates, or ii) the providers, authors or publishers of the forms, be responsible or liable for any direct, indirect, incideovided "AS-IS." We do not give any express or implied warranties of merchantability, suitability or completeness for any of the materials for your particular needs. The materials are used at your own erials. FindLegalForms, Inc. does not provide legal advice. The purchase and use of these materials is subject to the "Disclaimers and Terms of Use" found at findlegalforms.com. These materials are pran anatomical gift. During a terminal illness or injury, the refusal may be an oral statement or other form of communication. Disclaimer No Attorney-Client relationship is created by use of these matocument of gift, (ii) a statement attached to or imprinted on a donor's motor vehicle operator's or chauffeur's license, or (iii) any other writing used to identify the individual as refusing to make the consent or concurrence of any person after the donor's death. An individual may refuse to make an anatomical gift of the individual's body or part by (i) a writing signed in the same manner as a ddelivery of a signed statement to a specified donee to whom a document of gift had been delivered. An anatomical gift that is not revoked by the donor before death is irrevocable and does not require ) a signed statement; (2) an oral statement made in the presence of two individuals; (3) any form of communication during a terminal illness or injury addressed to a physician or surgeon; or (4) the f, after death, the will is declared invalid for testamentary purposes, the validity of the anatomical gift is unaffected. A donor may amend or revoke an anatomical gift, not made by will, only by: (1ze any physician, surgeon, technician, or enucleator to carry out the appropriate procedures. An anatomical gift by will takes effect upon death of the testator, whether or not the will is probated. In to carry out the appropriate procedures. In the absence of a designation or if the designee is not available, the donee or other person authorized to accept the anatomical gift may employ or authories, all of whom have signed at the direction and in the presence of the donor and of each other, and state that it has been so signed. A document of gift may designate a particular physician or surgeo least 18 years of age. An anatomical gift may be made by a document of gift signed by the donor. If the donor cannot sign, the document of gift must be signed by another individual and by two witness Instructions for preparing your Anatomical Gift Anatomical Gift Form To make an anatomical gift, limit an anatomical gift or refuse to make an anatomical gift, an individual must in most cases be atvides tools and guidelines to assist you in creating your Anatomical Gift and is designed to fulfill the obligations of the Uniform Anatomical Gift Act. Included in this kit are the following: Generalour wishes regarding the disposition of your body will be ignored. By preparing a written Anatomical Gift, you can rest assured that your desire to donate your organs will be carried out. This kit proFindLegalForms.com Information Donation Pursuant to the Uniform Anatomical Gift Act (by Living Donor) No one likes considering their own death, but by avoiding the subject, it is likely that many of y CaliforniaCalifornia ________ n whose name is subscribed to this instrument appears to be of sound mind and under no duress, fraud, or undue influence. _____________________________ Notary Public My commission expires ____________ersonally and, under oath, stated that he or she is the person described in the above document and he or she signed the above document in my presence. I declare under penalty of perjury that the perso_________________________________ Notary Acknowledgment (Optional) State of ____________________ County of ____________________ On ____________________, ______________________________ came before me pignature of Donor ______________________________ Printed Name of Donor Address: ____________________________________________ City: _______________________________________________ State: ______________y written revocation of my Anatomical Gift. This statement will be delivered to all specified donees, if any, to whom a document of gift had been previously delivered. ______________________________ Sication during a terminal illness or injury addressed to a physician or surgeon; or (4) the delivery of a signed statement to a specified donee to whom a document of gift had been delivered. This is m of this state, a donor may amend or revoke an anatomical gift, not made by will, only by: (1) a signed statement; (2) an oral statement made in the presence of two individuals; (3) any form of commun__________________, I, ______________________________, the donor, fully and completely revoke the Anatomical Gift dated __________________________. Pursuant to Uniform Anatomical Gift Act and the lawsft Act, you should check the laws of your state to determine whether there are any other requirements you must meet to revoke your Anatomical Gift. Revocation of Anatomical Gift On this date ________estroy the original and all copies of your Anatomical Gift or cross out each page of the forms and mark "REVOKED" across them in bold print. Although most states have adopted the Uniform Anatomical Giorm notarized. You should also make certain that a copy of any revocation is provided to anyone who has a copy of your original Anatomical Gift, including any designated donees. You should also then dted. When you have completed the form and printed it, sign the form and make certain that you store the original where you had stored the original of your Anatomical Gift. You may choose to have the f. An anatomical gift that is not revoked by the donor before death is irrevocable and does not require the consent or concurrence of any person after the donor's death. Complete the information requesm of communication during a terminal illness or injury addressed to a physician or surgeon; or (4) the delivery of a signed statement to a specified donee to whom a document of gift had been deliveredn of Anatomical Gift form. A donor may amend or revoke an anatomical gift, not made by will, only by: (1) a signed statement; (2) an oral statement made in the presence of two individuals; (3) any foray out of the use of these materials. An attorney should be consulted for all serious legal matters. Revoking Your Anatomical Gift Instructions Following these instructions, you will find a Revocatios of use, data, or profits; or business interruption) however caused and on any theory of liability, whether in contract, strict liability, or tort (including negligence or otherwise) arising in any w the forms, be responsible or liable for any direct, indirect, incidental, special, exemplary, or consequential damages (including, but not limited to, procurement of substitute goods or services; loserials for your particular needs. The materials are used at your own risk. In no event will: i) FindLegalForms, Inc, its agents, partners, or affiliates, or ii) the providers, authors or publishers ofand Terms of Use" found at findlegalforms.com. These materials are provided "AS-IS." We do not give any express or implied warranties of merchantability, suitability or completeness for any of the matlaimer No Attorney-Client relationship is created by use of these materials. FindLegalForms, Inc. does not provide legal advice. The purchase and use of these materials is subject to the "Disclaimers esigned to fulfill the requirements of the Uniform Anatomical Gift Act. Included in this kit is the following: General Instructions for Revoking Your Anatomical Gift Revocation of Anatomical Gift Discnt to revoke the document. Until your death, it is your right to revoke your Anatomical Gift at any time. This kit provides tools and guidelines to assist you in revoking your Anatomical Gift and is dFindLegalForms.com Information Revoking an Anatomical Gift (Organ Donation Revocation) You prepared a written Anatomical Gift, but now because of a change of circumstances or a change of heart, you wa CaliforniaCalifornia _____________ Name of Survivor: _______________________________ Address: ____________________________________________ City: _______________________________________________ State: __________________________________urposes (strike any of the following you do not want): (1) Transplant (2) Therapy (3) Research (4) Education Date: __________________ Signature of Survivor: __________________________________ Printed_______________ ________________________________________________________________________ ________________________________________________________________________ III. The gift is for the following pthe applicable box): Give any needed organs, tissues, or parts, OR Give the following organs, tissues, or parts only: _______________________ _________________________________________________________ity and state). I. I survive the decedent as (mark the appropriate box): spouse; adult son or daughter; parent; adult brother or sister; grandparent; or guardian of the decedent. II. I hereby (mark this anatomical gift from the body of __________________________________(name of decedent) who died on _____________, 20___ at_______________________________ in ____________________________________ (corney should be consulted for all serious legal matters. Anatomical Gift by Next of Kin or Guardian of the Person Pursuant to the Uniform Anatomical Gift Act and the law of this state, I hereby make rruption) however caused and on any theory of liability, whether in contract, strict liability, or tort (including negligence or otherwise) arising in any way out of the use of these materials. An att direct, indirect, incidental, special, exemplary, or consequential damages (including, but not limited to, procurement of substitute goods or services; loss of use, data, or profits; or business inteals are used at your own risk. In no event will: i) FindLegalForms, Inc, its agents, partners, or affiliates, or ii) the providers, authors or publishers of the forms, be responsible or liable for anym. These materials are provided "AS-IS." We do not give any express or implied warranties of merchantability, suitability or completeness for any of the materials for your particular needs. The materieated by use of these materials. FindLegalForms, Inc. does not provide legal advice. The purchase and use of these materials is subject to the "Disclaimers and Terms of Use" found at findlegalforms.con for the removal of a part from the body of the decedent, the physician, surgeon, technician, or enucleator removing the part knows of the revocation. Disclaimer No Attorney-Client relationship is cr a member of the person's class or a prior class. An anatomical gift by a person authorized under subdivision may be revoked by any member of the same or a prior class if, before procedures have beguoposing to make an anatomical gift knows of a refusal or contrary indications by the decedent. (3) The person proposing to make an anatomical gift knows of an objection to making an anatomical gift byAn anatomical gift may not be made by a person listed above if any of the following occur: (1) A person in a prior class is available at the time of death to make an anatomical gift. (2) The person pre decedent; (3) either parent of the decedent; (4) an adult brother or sister of the decedent; (5) a grandparent of the decedent; and (6) a guardian of the person of the decedent at the time of death ker for an authorized purpose, unless the decedent, at the time of death, has made an unrevoked refusal to make that anatomical gift: (1) the spouse of the decedent; (2) an adult son or daughter of th Gift Form An anatomical gift may be made any member of the following classes of persons, in the order of priority listed, may make an anatomical gift of all or part of the decedent's body or a pacemas made on behalf of the decedent by the next of kin or guardian. Included in this kit are the following: General Instructions for preparing your Anatomical Gift (by next of kin or guardian) Anatomicalt. As the next of kin or guardian, you can prepare and execute an Anatomical Gift on behalf of the decedent. This kit is designed to fulfill the obligations of the Uniform Anatomical Gift Act for giftFindLegalForms.com Information Donation Pursuant to the Uniform Anatomical Gift Act (by Next of Kin or Guardian) A loved one has died and you believe that he/she would desire to make an Anatomical Gif California