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District of Columbia Print Name: ___________________________________ Address: ______________________________________ Date:__________________ 2 Signature) Print Name: ___________________________________ Address: ______________________________________ Date:__________________ _____________________________________________ (Witness Signature) larant's attending physician, an employee of the attending physician, or an employee of the health facility in which the declarant is a patient. _____________________________________________ (Witnessor codicil thereto, or directly financially responsible for declarant's medical care. I am not the health-care provider of the declarant or an employee of the health-care provider of the principal decthe declarant by blood or marriage, entitled to any portion of the estate of the declarant according to the laws of intestate succession of the District of Columbia or under any will of the declarant and under no duress, fraud, or undue influence. I did not sign the declarant's 1 signature above for or at the direction of the declarant. I am at least eighteen years of age and am not related to _____________________ _____________________________________________________________________ I declare that the declarant is personally known to me and that I believe the declarant to be of sound mindn and that I am emotionally and mentally competent to make this declaration. Declarant's Signature: __________________________________________________ Address _________________________________________medical or surgical treatment and accept the consequences from such refusal. By my signature I indicate that I understand the purpose and effect of this document and the full import of this declaratiotions regarding the use of such life-sustaining procedures, it is my intention that this declaration shall be honored by my family and physician(s) as the final expression of my legal right to refuse ___ ____________________________________________________________________________ ____________________________________________________________________________ In the absence of my ability to give direc to alleviate pain. Other directions: (optional): ____________________________________________________________________________ _________________________________________________________________________thheld or withdrawn, and that I be permitted to die naturally with only the administration of medication or the performance of any medical procedure deemed necessary to provide me with comfort care orr or not life-sustaining procedures are utilized and where the application of life-sustaining procedures would serve only to artificially prolong the dying process, I direct that such procedures be wi certified to be a terminal condition by two physicians who have personally examined me, one of whom shall be my attending physician, and the physicians have determined that my death will occur whethetarily make known my desires that my dying shall not be artificially prolonged under the circumstances set forth below, do declare: If at any time I should have an incurable injury, disease or illnessde this __________ day of _______________________________.(date) (month, year) I, _____________________________________________________________________, (name) being of sound mind, willfully and volun should be discussed with a tax professional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Living Will DECLARATION Declaration mato make sure it fits 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 documentlegal and/or tax advice. Laws vary from time to time and from state to state. These forms should only be a starting point for you and should not be used or signed without consulting an attorney first ss warranties have been made or are provided as to their suitability for any specific purpose or as to their legal effect or completeness. [_]These forms are not intended and are not a substitute for ving Will. This District of Columbia Living Will is based on Title 21 Chapter 22 Section 21-2201 et. Seq. of the District of Columbia Code. [_] These forms are provided "as is" and no implied or expre_ Signature: _______________________________ -4- Information District of Columbia Living Will This package contains (1) Information for District of Columbia Living Will; (2) District of Columbia Liption, and, to the best of my knowledge, I am not entitled to any part of the estate of the principal under a currently existing will or by operation of law. Signature: _____________________________________________________________ (AT LEAST 1 OF THE WITNESSES LISTED ABOVE SHALL ALSO SIGN THE FOLLOWING DECLARATION.) I further declare that I am not related to the principal by blood, marriage or adognature: ______________________________________________ Home Address: __________________________________________ Print Name: _____________________________________________ Date: ________________________ Home Address: __________________________________________ Print Name: _____________________________________________ Date: ___________________________________________________ Second Witness Si by this document, nor am I the health-care provider of the principal or an employee of the health-care provider of the principal. First Witness Signature: __________________________________________ of attorney for health care in my presence, and that the person appears to be of sound mind and under no duress, fraud, or undue -3- influence. I am not the person appointed as the attorney in fact________________________ (Signature) WITNESSES I declare that the person who signed or acknowledged this document is personally known to me, that the person signed or acknowledged this durable powerFFECT OF THIS DOCUMENT. I sign my name to this form on _________________________________________ (date) at: _________________________________________________________________ (address). _______________________________________________________________________ ______________________________________________________________________________ BY MY SIGNATURE I INDICATE THAT I UNDERSTAND THE PURPOSE AND E____________________ ______________________________________________________________________________ ______________________________________________________________________________ _________________________________________ (b) SPECIAL PROVISIONS AND LIMITATIONS: ______________________________________________________________________________ ________________________________________________________________________________________________________________________ ______________________________________________________________________________ ___________________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ________________ to my attorney in fact in some other way. (a) STATEMENT OF DIRECTIVES CONCERNING LIFE-PROLONGING CARE, TREATMENT, SERVICES, AND PROCEDURES: -2- _____________________________________________________effect if I become incapable of making my own health-care decisions and shall continue during that incapacity. My attorney in fact shall make health-care decisions as I direct below or as I make known _____________________________________________________________________________ (home phone) (work phone) With this document, I intend to create a power of attorney for health care, which shall take _____________________________________________________________________________ (name) _____________________________________________________________________________ (address) (city) (state) (zip code)_______________________________________________________ (address) (city) (state) (zip code) _____________________________________________________________________________ (home phone) (work phone) 2. my attorney in fact, I appoint the following person to serve in the order listed below: 1. _____________________________________________________________________________ (name) ______________________he authority to talk to health-care personnel, get information and sign forms necessary to carry out these decisions. If the person named as my attorney in fact is not available or is unable to act asn health-care decisions. This gives my attorney in fact the power to grant, refuse, or withdraw consent on my behalf for any health-care service, treatment or procedure. My attorney in fact also has t) _____________________________________________________________________________ (home phone) (work phone) as my attorney in fact to make health-care decisions for me if I become unable to make my ow________________________________________ (name of individual you choose as agent) -1- _____________________________________________________________________________ (address) (city) (state) (zip codeENT SHOULD BE INCLUDED IN YOUR MEDICAL RECORD. POWER OF ATTORNEY FOR HEALTH CARE I, ____________________________________________________________, hereby appoint: _____________________________________AIN IT TO YOU. YOU SHOULD KEEP A COPY OF THIS DOCUMENT AFTER YOU HAVE SIGNED IT. GIVE A COPY TO THE PERSON YOU NAME AS YOUR ATTORNEY IN FACT. IF YOU ARE IN A HEALTH-CARE FACILITY, A COPY OF THIS DOCUMD TO PLACE COPIES OF THE REVOCATION WHEREVER THIS DOCUMENT IS LOCATED. IF THERE IS ANYTHING IN THIS DOCUMENT THAT YOU DO NOT UNDERSTAND, YOU SHOULD ASK A SOCIAL WORKER, LAWYER, OR OTHER PERSON TO EXPLD INCOMPETENT, BY NOTIFYING YOUR ATTORNEY IN FACT OR HEALTH-CARE PROVIDER EITHER ORALLY OR IN WRITING. SHOULD YOU REVOKE THE AUTHORITY OF YOUR ATTORNEY IN FACT, IT IS ADVISABLE TO REVOKE IN WRITING ANENT ANY TYPE OF TREATMENT THAT YOU DO NOT DESIRE AND ANY THAT YOU WANT TO MAKE SURE YOU RECEIVE. YOU HAVE THE RIGHT TO TAKE AWAY THE AUTHORITY OF YOUR ATTORNEY IN FACT, UNLESS YOU HAVE BEEN ADJUDICATEO SO. IN ADDITION, AFTER YOU HAVE SIGNED THIS DOCUMENT, NO TREATMENT MAY BE GIVEN TO YOU OR STOPPED OVER YOUR OBJECTION IF YOU ARE MENTALLY COMPETENT TO MAKE THAT DECISION. YOU MAY STATE IN THIS DOCUME DECISIONS FOR YOU IF YOU CANNOT MAKE THE DECISIONS FOR YOURSELF. AFTER YOU HAVE SIGNED THIS DOCUMENT, YOU HAVE THE RIGHT TO MAKE HEALTH-CARE DECISIONS FOR YOURSELF IF YOU ARE MENTALLY COMPETENT TO DTANT LEGAL DOCUMENT. BEFORE SIGNING THIS DOCUMENT, IT IS VITAL FOR YOU TO KNOW AND UNDERSTAND THESE FACTS: THIS DOCUMENT GIVES THE PERSON YOU NAME AS YOUR ATTORNEY IN FACT THE POWER TO MAKE HEALTH-CAR The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com -3- Power of Attorney for Health Care INFORMATION ABOUT THIS DOCUMENT THIS IS AN IMPORn. You should also consult an attorney whenever a document is negotiated with another party. Any possible tax consequences arising out of this document should be discussed with a tax professional. [_]oint for you and should not be used without consulting with an attorney first. Before using or signing this document you should have an attorney review it to make sure it fits your particular situatiofect 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 forms should only be a starting p alternative language: [_] 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 ef1-2205 may be used to create a durable power of attorney for health care. The following is offered as a sample form only and its inclusion in this section shall not be construed to preclude the use ofthe former spouse but may be subsequently revoked by an act of the principal. § 21-2207. Forms for creating a durable power of attorney for health care Any written form meeting the requirements of § 2use as an attorney in fact to make health-care decisions for the principal. If a designation is revoked solely on account of this subsection, it shall be revived by the remarriage of the principal to re expressly provides otherwise, and after its execution the marriage of the principal is dissolved or annulled, the dissolution or annulment shall automatically revoke a designation of the former spoy provides otherwise, a valid durable power of attorney for health care revokes any prior durable power of attorney for health-care decisions only. (e) Unless a durable power of attorney for health ca revocation. (c) There shall be a rebuttable presumption, affecting the burden of proof, that a principal has the capacity to revoke a durable power of attorney for health care. (d) Unless it expressl to subsection (a)(2) of this section, the health-care provider shall document this fact in the patient-care records of the principal and make a reasonable effort to notify the attorney in fact of theto the attorney in fact under a durable power of attorney for health care by notifying the health-care provider orally or in writing. (b) If a health-care provider is notified of a revocation pursuantent of the attorney in fact under a durable power of attorney for health care by notifying the attorney in fact orally or in writing; or (2) Revoke the authority to make health-care decisions granted ehalf of the principal. § 21-2208. Revocation -2- (a) At any time that the principal has the capacity to create a durable power of attorney for health care, the principal may: (1) Revoke the appointm shall affect any right that an attorney in fact may have, independent of the designation in a durable power of attorney for health care, to make or otherwise participate in health-care decisions on b care; or (2) The good faith belief of the attorney in fact as to the best interests of the principal, if the wishes of the principal are unknown and cannot be ascertained. (d) Nothing in this chapter a durable power of attorney for health care, the attorney in fact shall have a duty to act in accordance with: (1) The wishes of the principal as expressed in the durable power of attorney for health shall not have the authority to make a particular health-care decision, if the principal is able to give or withhold informed consent with respect to that decision. (c) In exercising authority underilable and willing to make a particular health-care decision, shall have priority over any other person to act for the principal in all matters regarding health care. (2) A designated attorney in factas provided in paragraph (2) of this subsection and unless a durable power of attorney for health care provides otherwise, the designated attorney in fact, if known to a health-care provider to be avand (5) The authority to make decisions regarding admission to or discharge from healthcare facilities and to take any lawful actions that may be necessary to carry out these decisions. (b) (1) Except care records of the principal; (3) The right to be provided with all information necessary to make informed healthcare decisions; (4) The authority to select and discharge health-care professionals; as authority shall include, at a minimum: (1) The authority to grant, refuse or withdraw consent to the provision of any healthcare service, treatment, or procedure; (2) The right to review the health ower of attorney for health care, an attorney in fact shall have all the rights, powers and authority related to health-care decisions that the principal would have under District and federal law. Thiffective, if the execution of the prior document meets the requirements of this chapter. -1- § 21-2206. Rights and duties of attorney in fact. (a) Subject to any express limitations in the durable pl or operation of law. (e) Any durable power of attorney for health care executed prior to March 16, 1989, and specifically written to include health-care decision making after incompetency shall be ein subsection (c) of this section, at least 1 shall not be related to the principal by blood, marriage or adoption and shall not be entitled to any part of the estate of the principal by a current wil The 2 adult witnesses shall not include the principal, the health-care provider of the principal or an employee of the health-care provider of the principal. (d) Of the 2 adult witnesses referred to durable power of attorney for health care shall be dated and signed by the principal and 2 adult witnesses who affirm that the principal was of sound mind and free from duress at the time of signing.lowing: (1) "This power of attorney shall not be affected by the subsequent incapacity of the principal."; or (2) "This power of attorney becomes effective upon the incapacity of the principal." (c) Athat the principal intends the attorney in fact to have the authority to make health-care decisio ns on behalf of the principal and shall include language identical or substantially similar to the folf mental disability, of making or communicating a choice regarding a particular health-care decision. (b) A durable power of attorney for health care shall include language which clearly communicates A competent adult may designate, in writing, an individual who shall be empowered to make health-care decisions on behalf of the competent adult, if the competent adult becomes incapable, by reason oowing are useful excerpts from the District of Columbia Statutes relating to the District of Columbia Power of Attorney for Health Care Form. § 21-2205. Durable power of attorney for health care. (a) Power of Attorney for Health Care Form. This District of Columbia Power of Attorney for Health Care is based on Title 21 Chapter 22 Section 21-2205 et. Seq. of the District of Columbia Code. The follctions District of Columbia Power of Attorney for Health Care This package contains (1) Information and Instruction for District of Columbia Power of Attorney for Health Care; (2) District of Columbiaof this document should be discussed with a tax professional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Information and Instru attorney first to make sure it fits your particular situation. Advice from a local attorney is always recommended when dealing with estate planning matters. Any possible tax consequences arising out substitute for legal and/or tax advice. Laws vary from time to time and from state to state. These forms should only be a starting point for you and should not be used or signed without consulting animplied or express warranties have been made or are provided as to their suitability for any specific purpose or as to their legal effect or completeness. [_]These forms are not intended and are not a also sometimes known as an Advance Health 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 District of Columbia Advance Health Care Directive This package contains both a District of Columbia Power of Attorney for Health Care and a District of Columbia Living Will. Together these forms are District of Columbia