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Colorado ______ day of __________, 20___. My commission expires: _________________________ (Notary Public) 2 _________________________ the declarant, and _________________________________________ and _________________________________________ witnesses, as the voluntary act and deed of the declarant this ____e: ___________________________________ Address: ______________________________________ STATE OF COLORADO ) ) ss. County of ___________________ ) SUBSCRIBED and sworn to before me by ________________________ (Witness Signature) Print Name: ___________________________________ Address: ______________________________________ _____________________________________________ (Witness Signature) Print Nam our best knowledge and belief, was of sound mind and under no constraint or undue influence. Dated at __________, Colorado, this ______ day of __________, 20___. _____________________________________ence, in the presence of each other, and at his request, have signed our names below as witnesses, and we declare that, at the time of 1 the execution of this instrument, the declarant, according to__. By: _______________________________ (Declarant) The foregoing instrument was signed and declared by _________________________________ to be his declaration, in the presence of us, who, in his presdeclarant) c. Artificial nourishment shall be continued when it is the only procedure being provided. 3. I execute this declaration, as my free and voluntary act, this ______ day of _____________, 20_ocedure being provided; or ____________ (initials of declarant) b. Artificial nourishment shall be continued for ______ days when it is the only procedure being provided; or ____________ (initials of ng provided is artificial nourishment, I direct that one of the following actions be taken: ____________ (initials of declarant) a. Artificial nourishment shall not be continued when it is the only pry specifically direct, in accordance with Colorado law, that artificial nourishment be withdrawn or withheld pursuant to the terms of this declaration. 2. In the event that the only procedure I am beit life-sustaining procedures shall not include any medical procedure or intervention for nourishment considered necessary by the attending physician to provide comfort or alleviate pain. However, I maconcerning my person, then I direct that, in accordance with Colorado law, life-sustaining procedures shall be withdrawn and withheld pursuant to the terms of this declaration, it being understood tha terminal condition, and b. For a period of seven consecutive days or more, I have been unconscious, comatose, or otherwise incompetent so as to be unable to make or communicate responsible decisions ny time my attending physician and one other qualified physician certify in writing that: a. I have an injury, disease, or illness which is not curable or reversible and which, in their judgment, is a declarant), being of sound mind and at least eighteen years of age, direct that my life shall not be artificially prolonged under the circumstances set forth below and hereby declare that: 1. If at ais subject to the Disclaimers and Terms of Use found at findlegalforms.com Living Will Declaration As To Medical Or Surgical Treatment I, ____________________________________________________ (name of 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 use of these forms rms 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 attorney is alwayspurpose or as to their legal effect or completeness. [_]These forms are not intended and are not a substitute for legal and/or tax advice. Laws vary from time to time and from state to state. These foelling, obliterating, or destroying said declaration. [_] 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 are facility, the witnesses shall not be patients of that facility. 15-18-109. Revocation of declaration. A declaration may be revoked by the declarant orally, in writing, or by burning, tearing, cancall be signed by the declarant in the presence of two witnesses. Said witnesses shall not include any person specified in section 15-18-105. (2) If the declarant is a patient or resident of a health con of the estate of the declarant upon his death either as a beneficiary of a will in existence at the time the declaration is signed or as an heir at law. 15-18-106. Witnesses. (1) The declaration sh) A person who has a claim against any portion of the estate of the declarant at his death at the time the declaration is signed; or (d) A person who knows or believes that he is entitled to any porti) The attending physician or any other physician; or Information & Instructions ­ Page 3 (b) An employee of the attending physician or health care facility in which the declarant is a patient; or (cIn the event that the declarant is physically unable to sign the declaration, it may be signed by some other person in the declarant's presence and at his direction. Such other person shall not be: (ases by any competent adult shall be legally effective for the purposes of this article and may, but need not, be in the following form: (see form below) 15-18-105. Inability of declarant to sign. (1) ance of artificial nourishment, he may order that such nourishment be provided but only to the extent necessary to provide comfort and alleviate such pain. (3) A declaration executed before two witneshis subsection (2.5). (2.6) Notwithstanding the provisions of subsection (2.5) of this section and section 15-18-103 (7), when an attending physician has determined that pain results from a discontinuI) That artificial nourishment be continued when it is the only procedure being provided. (b) A declaration executed prior to March 29, 1989, may be amended by a codicil to include the provisions of tment not be continued when it is the only procedure being provided; or (II) That artificial nourishment be continued for a specified period of time when it is the only procedure being provided; or (IIe declarant may provide in his declaration that, in the event that the only procedure being provided is artificial nourishment, one of the following actions shall be taken: (I) That artificial nourishasonable degree of medical certainty develop to live birth with continued application of lifesustaining procedures. If such is the case, the declaration shall be given no force or effect. (2.5) (a) Thecord. (2) In the case of a declaration of a qualified patient known to the attending physician to be pregnant, a medical evaluation shall be made as to whether the fetus is viable and could with a reon should be accepted or rejected. It shall be the responsibility of the declarant or someone acting for him to submit the declaration to the attending physician for entry in the declarant's medical rtaining procedures be withheld or withdrawn if, at some future time, he is in a terminal condition and either unconscious or otherwise incompetent to decide whether any medical procedure or interventiire any person to execute a declaration. Information & Instructions ­ Page 2 15-18-104. Declaration as to medical treatment. (1) Any competent adult may execute a declaration directing that life-sused medical ethics or protocol with respect to any patient in the absence of a declaration as provided for in section 15-18-104; (g) It is the legislative intent that nothing in this article shall requadvance, before he becomes unconscious or otherwise incompetent to do so; (f) It is the legislative intent that nothing in this article shall have the effect of modifying or changing currently practic (e) This article affirms the traditional right to accept or reject medical or surgical treatment affecting one's person, and creates a procedure by which a competent adult may make such decisions in ffered or applied when he is suffering from a terminal condition and is either unconscious or otherwise incompetent to decide whether such medical or surgical treatment should be accepted or rejected;The traditional right to accept or reject medical or surgical treatment should be available to an adult while he is competent, notwithstanding the fact that such medical or surgical treatment may be oe use of such medical or surgical procedures increasingly involves patients who are unconscious or otherwise incompetent to accept or reject medical or surgical treatment affecting their persons; (d) cting his person; (b) Recent advances in medical science have made it possible to prolong dying through the use of artificial, extraordinary, extreme, or radical medical or surgical procedures; (c) Th1) The general assembly hereby finds, determines, and declares that: (a) Colorado law has traditionally recognized the right of a competent adult to accept or reject medical or surgical treatment affe AND FIDUCIARIES : DECLARATIONS - FUTURE MEDICAL TREATMENT : ARTICLE 18 COLORADO MEDICAL TREATMENT DECISION ACT : 15-18-104. Declaration as to medical treatment. 15-18-102. Legislative declaration. (15 Article 18 Section 15-18-104 et. Seq. of the Colorado Statutes. For your convenience, we have included useful excerpts from the Colorado Statutes relating to Living Wills. TITLE 15 PROBATE, TRUSTS,Information and Instructions Colorado Living Will This package contains (1) Information and Instruction for Colorado Living Will; (2) Colorado Living Will. This Colorado Living Will is based on Title Colorado