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Georgia care of the patient. 3 cal director of skilled nursing facility or staff physician not participating in care of the patient or chief of the hospital medical staff or staff physician or hospital designee not participating in I hereby witness this living will and attest that I believe the declarant to be of sound mind and to have made this living will willingly and voluntarily. Witness: ___________________________ Medire) Print Name: ___________________________________ Address: ______________________________________ Additional witness required when living will is signed in a hospital or skilled nursing facility. 2_____________________ (Witness Signature) Print Name: ___________________________________ Address: ______________________________________ _____________________________________________ (Witness Signatu no present claim against any portion of the estate of the declarant; (4) Declarant has signed this document in my presence as above instructed, on the date above first shown. ________________________tending physician or an employee of the hospital or skilled nursing facility in which declarant is a patient; (d) Am not directly financially responsible for the declarant's medical care; and (e) Haveportion of the declarant's estate by any will or by operation of law under the rules of descent and distribution of this state; (c) Am not the attending physician of declarant or an employee of the atleast 18 years of age; (3) To the best of my knowledge, at the time of the execution of this living will, I: (a) Am not related to the declarant by blood or marriage; (b) Would not be entitled to any of Residence). I hereby witness this living will and attest that: (1) The declarant is personally known to me and I believe the declarant to be at least 18 years of age and of sound mind; (2) I am at ) 1 Signed ___________________________________________________________ _________________________________ (City), ____________________(County), and ___________________________________________ (State gnant, this living will shall have no force and effect unless the fetus is not viable and I indicate by initialing after this sentence that I want this living will to be carried out. _________(Initialtand the full import of this living will, and I am at least 18 years of age and am emotionally and mentally competent to make this living will; and 5. If I am a female and I have been diagnosed as prehe final expression of my legal right to refuse medical or surgical treatment and accept the consequences from such refusal; 3. I understand that I may revoke this living will at any time; 4. I underse; 2. In the absence of my ability to give directions regarding the use of such life-sustaining procedures, it is my intention that this living will shall be honored by my family and physician(s) as ton desired): [__] including nourishment and hydration, [__] including nourishment but not hydration, or [__] excluding nourishment and hydration, be withheld or withdrawn and that I be permitted to dires set forth in paragraphs (2), (9), and (13) of Code Section 31-32-2 of the Official Code of Georgia Annotated, I direct that the application of life-sustaining procedures to my body (check the opti consciousness, or [__] become in a persistent vegetative state with no reasonable expectation of regaining significant cognitive function, as defined in and established in accordance with the procedu circumstances set forth below and do declare: 1. If at any time I should (check each option desired): [__] have a terminal condition, [__] become in a coma with no reasonable expectation of regaining________ (month, year). I, __________________________________________________________, being of sound mind, willfully and voluntarily make known my desire that my life shall not be prolonged under thetax professional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Living Will DECLARATION Living will made this ______ day of ______rticular situation. Advice from a local attorney is always recommended when dealing with estate planning matters. Any possible tax consequences arising out of this document should be discussed with a s 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 to make sure it fits your paty for any specific purpose or as to their legal effect or completeness. Information & Instructions ­ Page 3 [_]These forms are not intended and are not a substitute for legal and/or tax advice. Law criminal immunity otherwise granted under this chapter for such conduct. [_] These forms are provided "as is" and no implied or express warranties have been made or are provided as to their suitabilil of life-sustaining procedures pursuant to a living will, as authorized by this chapter, which person has actual knowledge that such living will has been properly revoked, shall not have any civil orhe time, date, and place of the revocation and the time, date, and place, if different, when he received notification of the revocation. (b) Any person who participates in the withholding or withdrawative only upon communication to the attending physician by the declarant or by a person acting at the direction of the declarant. The attending physician shall record in the patient's medical record tffective, such an oral revocation must clearly express an intention to revoke a living will as opposed to a will relating to the disposition of property after death. Such revocation shall become effececord the time and date when he received notification of the written revocation; or (3) By any verbal or nonverbal expression by the declarant of his intent to revoke the living will. In order to be ee effective only upon communication to the attending physician by the declarant or by a person acting at the direction of the declarant. The attending physician shall record in the patient's medical rs for the revocation of "all other wills" of the testator shall not operate to revoke a living will without further evidence of a specific intent to revoke the living will. Such revocation shall becomthout limiting the generality of the foregoing, it is specifically provided that the revocation clause which is customarily included in a will relating to the disposition of property and which provide In order to be effective, such a written revocation must clearly express an intention to revoke a living will as opposed to a will or wills relating to the disposition of property after death; and win his presence and by his direction; (2) By the declarant or a person acting at the direction of the declarant signing and dating a written revocation expressing the intent of the declarant to revoke.without regard to his mental state or competency, by any of the following methods: (1) By being canceled, defaced, obliterated, burnt, torn, or otherwise destroyed by the declarant or by some person iy physician on the medical staff who is not participating in the care of the patient, if witnessed in a skilled nursing facility. 31-32-5 (a) A living will may be revoked at any time by the declarant,tructions ­ Page 2 staff who is not participating in the care of the patient designated by the chief of staff and the hospital administrator, if witnessed in a hospital, or the medical director or ann the presence of either the chief of the hospital medical staff, any physician on the medical staff who is not participating in the care of the patient, or a person on the hospital Information & Inskilled nursing facility at the time the living will is executed unless the living will is signed in the presence of the two witnesses as provided in Code Section 31-32-3 and, additionally, is signed intially the form specified under prior law shall be presumed on its face to be valid and effective: 31-32-4 A living will shall have no force or effect if the declarant is a patient in a hospital or sed, regardless of the form used or when executed. Declarations executed on or after March 28, 1986, shall be valid indefinitely unless revoked. A declaration similar to the following form or in substay portion of the estate of the declarant. (b) The declaration shall be a document, separate and self-contained. Any declaration which constitutes an expression of the declarant's intent shall be honore of the hospital or skilled nursing facility in which the declarant is a patient; (4) Are not directly financially responsible for the declarant's medical care; and (5) Do not have a claim against anr the rules of descent and distribution of this state at the time of the execution of the living will; (3) Are neither the attending physician nor an employee of the attending physician nor an employeion of the estate of the declarant upon the declarant's decease under any testamentary will of the declarant, or codicil thereto, and would not be entitled to any such portion by operation of law unde competent adults who, at the time of the execution of the living will, to the best of their knowledge: (1) Are not related to the declarant by blood or marriage; (2) Would not be entitled to any portt directing that, should the declarant have a terminal condition, life-sustaining procedures be withheld or withdrawn. Such living will shall be signed by the declarant in the presence of at least two-32-3 et. Seq. of the Georgia Statutes. For your convenience, we have included useful excerpts from the Georgia Statutes relating to Living Wills. 31-32-3 (a) Any competent adult may execute a documenInformation and Instructions Georgia Living Will This package contains (1) Information and Instruction for Georgia Living Will; (2) Georgia Living Will. This Georgia Living Will is based on Section 31 Georgia