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Florida Phone: _______________________________________ 2 _____________________________________ _____________________________________________ (Witness Signature) Print Name: ___________________________________ Address: __________________________________________ (Declarant's Signature) _____________________________________________ (Witness Signature) Print Name: ___________________________________ Address: ______________________________________ Phone: ________ ____________________________________________________________________________ ____________________________________________________________________________ __________________________________________________________________________________________ ____________________________________________________________________________ _________________________________________________________________________________________ I understand the full import of this declaration, and I am emotionally and mentally competent to make this declaration. Additional Instructions (optional): __________________________________________________________________________________________ ______________________________________ Zip Code: ___________________________ Phone: _________________________________________________to carry out the provisions of this declaration should my surrogate be unwilling or unable to act on my behalf: 1 Name: ____________________________________________________________________ Address: _________________ Zip Code: ___________________________ Phone: ____________________________________________________________________ I wish to designate the following person as my alternate surrogate, isions of this declaration: Name: ____________________________________________________________________ Address: __________________________________________________________________ _____________________ed to be unable to provide express and informed consent regarding the withholding, withdrawal, or continuation of life-prolonging procedures, I wish to designate, as my surrogate to carry out the provred by my family and physician as the final expression of my legal right to refuse medical or surgical treatment and to accept the consequences for such refusal. In the event that I have been determinnly the administration of medication or the performance of any medical procedure deemed necessary to provide me with comfort care or to alleviate pain. It is my intention that this declaration be honoifeprolonging procedures be withheld or withdrawn when the application of such procedures would serve only to prolong artificially the process of dying, and that I be permitted to die naturally with o(initial) and if my attending or treating physician and another consulting physician have determined that there is no reasonable medical probability of my recovery from such condition, I direct that le that, if at any time I am incapacitated and _________ I have a terminal condition; or (initial) _________ I have an end-stage condition; or (initial) _________ I am in a persistent vegetative state _ day of _____, ______ (year), I, __________, willfully and voluntarily make known my desire that my dying not be artificially prolonged under the circumstances set forth below, and I do hereby declar 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 made this ____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 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 etative state. (c) Any limitations or conditions expressed orally or in a written declaration have been carefully considered and satisfied. [_] These forms are provided "as is" and no implied or exprecal probability of recovering capacity so that the right could be exercised directly by the principal. (b) The principal has a terminal condition, has an end-stage condition, or is in a persistent veg instructions. Information & Instructions ­ Page 2 (2) Before proceeding in accordance with the principal's living will, it must be determined that: (a) The principal does not have a reasonable medision is not sought within 7 days following the attending physician's decision to withhold or withdraw life-prolonging procedures, the attending physician may proceed in accordance with the principal'sold or withdraw life-prolonging procedures, the attending physician shall not withhold or withdraw life-prolonging procedures pending review under s. Ch765. Section 105. If a review of a disputed deciate under part II, the attending physician may proceed as directed by the principal in the living will. In the event of a dispute or disagreement concerning the attending physician's decision to withhng will expressing his or her desires concerning lifeprolonging procedures, but has not designated a surrogate to execute his or her wishes concerning life-prolonging procedures or designated a surroglishes a rebuttable presumption of clear and convincing evidence of the principal's wishes. Florida Statutes Title 44 Chapter 765 Section 304: Procedure for living will (1) If a person has made a livir health care facility which is so notified shall promptly make the living will or a copy thereof a part of the principal's medical records. (3) A living will, executed pursuant to this section, estabhe time the principal is admitted to a health care facility, any other person may notify the physician or health care facility of the existence of the living will. An attending or treating physician oy of the principal to provide for notification to her or his attending or treating physician that the living will has been made. In the event the principal is physically or mentally incapacitated at tal is physically unable to sign the living will, one of the witnesses must subscribe the principal's signature in the principal's presence and at the principal's direction. (2) It is the responsibilittent vegetative state. A living will must be signed by the principal in the presence of two subscribing witnesses, one of whom is neither a spouse nor a blood relative of the principal. If the principten declaration and direct the providing, withholding, or withdrawal of life-prolonging procedures in the event that such person has a terminal condition, has an end-stage condition, or is in a persislating to Living Wills. Florida Statutes Title 44 Chapter 765 Section 302: Procedure for making a living will; notice to physician. (1) Any competent adult may, at any time, make a living will or writms; (2) Florida Living Will. This Florida Living Will is based on Florida Statutes Title 44 Chapter 765 Section 303. For your convenience, we have included useful excerpts from the Florida Statutes reInformation and Instructions Florida Living Will This package contains (1) Information and Instruction for Florida Living Will, including excerpts from the Florida Statutes relating to Living Will For Florida