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Illinois _________________ Name typed, printed, or stamped -5- onally known to me or who has produced ________________________________ as identification. _________________________________ Signature of person taking acknowledgment (Notary Public) ________________s County of ________________________ ) The foregoing instrument was acknowledged before me this _____ day of ____________________, ______ by __________________________ (name of Principal), who is perss Signature: ___________________________________ Name: ___________________________________ City: __________________________________ State: ___________________________________ State of ILLINOIS ) ) sof Principal Witness Signature: ___________________________________ Name: ___________________________________ City: __________________________________ State: ___________________________________ Witnes this Power of Attorney at any time by providing written notice to my Agent. Signed on ________________ (date), at _______________________ (city), Illinois. ________________________________ Signature good faith. 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 relying in good faith on the authority of this document, without notice of such termination, shall be held harmless. -4- Agent shall not be liable for losses resulting from judgment errors made in demnify the 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 receives a 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 inrights or ownership 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 whoAgent based 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 effect and not 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 any manner. 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 be construed 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 or any authorized 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 result of carrying 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 te information effectively, to communicate decisions, and/or to manage my financial resources and affairs properly. My Agent shall be entitled to reimbursement of all reasonable expenses incurred as aent disability, incapacity or lack of mental competence (except as provided by any applicable statute). As used herein, "disability" or "incapacity" shall mean a lack of capacity to receive and evaluaecution of this instrument. The rights, powers, and authority of this document shall remain in full force and effect thereafter until my death. This Power of Attorney shall not terminate on my subsequclaimed assets pass directly or indirectly to my Agent or my Agent's estate. This Durable Power of Attorney and the rights, powers, and authority of my Agent shall become effective immediately upon existributed to me from any other person, estate, trust, or other entity, as may be appropriate. However, Agent may not disclaim assets, to -3- which I would be entitled, if the result is that the disee of any revocable trust created by me, if such trust exists at the time of such transfer. 17. To disclaim any interest (subject to other provisions of this document), which might be transferred or d Agent's legal obligations, including any obligations of support which my Agent may owe to others, excluding those whom I am legally obligated to support. 16. To transfer any of my assets to the trust) exercise any powers of appointment I may hold in favor of my Agent, my Agent's estate, my Agent's creditors, or the creditors of my Agent's estate, or (c) use any of my assets to discharge any of myt, (a) gift, appoint, assign or designate any of my assets, interests or rights, directly or indirectly, to my Agent, my Agent's estate, my Agent's creditors, or the creditors of my Agent's estate, (bount in any one calendar year, and this annual right shall be non-cumulative and shall lapse at the end of each calendar year. However, my Agent may not, unless specifically authorized by this documenthe Uniform Transfers To Minors Act. Any gifts made shall be limited to gifts that qualify for the federal gift tax annual exclusion, shall not exceed in value the federal gift tax annual exclusion am state and federal gift tax returns and documents. Gifts to minors may be made to the minor directly or parent, guardian or close friend of the minor or pursuant to the Uniform Gifts to Minors Act or f my real, personal, tangible or intangible property, to such persons or organizations without regard to whether such gifts are a part of my estate planning or otherwise, and if necessary, to file anyon to and from any agency, including governmental agencies, relating to tax matters and to negotiate, compromise or settle any matter with such agency. 15. To make gifts and charitable contributions oal, state, local or other governmental body, including, but not limited to, federal, state, local or other income and tax returns and necessary and/or related documents; to obtain or provide informati including but not limited to, attorneys, accountants, investment professionals, brokers and real estate agents. 14. To prepare, or cause to be prepared, sign, and/or file any documents with any federd/or operate any business that I currently own or have an interest in or may own or have an interest in, in the future. 13. To employ any professional and/or business assistance as may be appropriate,erwise dispose of the contents. 11. To exercise any and all rights, including proxy rights, with respect to stocks, bonds, debentures, commodities, options or any other investments. 12. To maintain anaccess to any safe deposit box, vault or other storage area owned or leased by me alone or in conjunction with any other person, including access to their contents, and to examine, remove, keep or othitical entity; to perform any act necessary to deposit, negotiate, sell or transfer any note, security, or draft of the United States of America, including U.S. Treasury Securities. -2- 10. To have checks or other instruments, obtaining bank statements, passbooks, drafts, warrants, money orders, certificates, cashier checks, cash or vouchers payable to me by any person, firm, corporation or polions; to conduct any business with any banking or financial institution with respect to any of my accounts, including, but not limited to, making deposits and withdrawals, negotiating or endorsing any but not limited to, checking accounts, savings accounts, certificates of deposit, investment accounts, brokerage accounts, retirement plan accounts, and other similar accounts with financial institutfits), and to appoint anyone, including my Agent, to act as my "Representative Payee" for the purpose of receiving Social Security benefits. 9. To open, maintain and/or close bank accounts, including,formation, and perform any other reasonable request by any government or its agencies in connection with governmental benefits (including but not limited to, medical, military and social security bene any annuity, pension, retirement benefits, retirement plans, insurance benefits and government program including, but not limited to, Social Security and Medicare; to prepare applications, provide inhe life of any other appropriate person and to make any elections and disclaimers under such policies. 8. To receive, deposit, hold, demand, deal with and/or sue to recover all payments I receive from due and owing to me by reason of such transaction. 7. To apply for, purchase, maintain and/or deal with insurance and annuity contracts, insurance policies, including life insurance upon my life or ttead that I now own or may own in the future; the right to remove tenants and to recover possession; and the right to ask for, demand, sue for, collect, recover and receive all monies which may becomeangible or intangible (now owned or acquired in the future by me) and to execute any necessary document, instrument or deed for such transactions. This includes the right to sell or encumber any homesxchange, invest, reinvest and in any other manner (on such terms and at prices my Agent may deem proper) deal with all, any part or any interest in any real or personal property or asset whatsoever, td by, due, owing payable, or belonging to, me or in which I have or may hereafter acquire any interest, to have, or use. 6. To maintain, manage, insure, lease, rent, sell, mortgage, improve, repair, etion, bequests, deposits, notes, interests, dividends, certificates of deposit, any and all documents of title and demands whatsoever, whether agreed to or disputed, now due or due in the future, ownerted on my behalf against any other person or entity. -1- 5. To receive, hold, possess and/or invest any and all sums of money, accounts, debts, bonds, commercial papers, checks, drafts, causes of acy be. 3. To request, ask, demand, sue and take any and all legal steps necessary to recover and collect any amount or debt owed to me. 4. To adjust, compromise and settle any claim, against me or assevidences of debts, releases, and satisfaction of mortgages, lien, judgments, security agreements and other debts and obligations and such other instruments in writing of whatever kind and nature as maercial papers, withdrawal and deposit slips, certificates of deposit of, or investments with or through banks, savings and loan, brokers, mutual fund companies or other institutions, proofs of loss, eeeds, options, trust deeds, security agreements, leases, mortgages, notes, insurance policies, receipts, title documents, checks, drafts, letters of credit, stock certificates, proxies, warrants, commnt and document necessary to enter into any such contract and/or agreement, including but not limited to applications, assignments, bills of sale or lading, bonds, contracts, covenants, conveyances, d, and transact any and all lawful business of whatever kind or nature, on my behalf and in my name. 2. To enter into binding contracts on my behalf and to sign, endorse and execute any written agreeme shall lawfully do or cause to be done by virtue of this power of attorney and the rights hereby granted. My Agent's powers and authority shall include, but not be limited to: 1. To conduct, engage inoperty, real or personal, tangible or intangible, or matter whatsoever as I could do if personally present. I hereby ratify and confirm all acts that my Agent, or my Agent's substitute or substitutes,uthority to perform any act, power, duty, legal right or obligation whatsoever that I now have or may later acquire in connection with or relating to any person, item, transaction, thing, business, prent") maintaining an address at: _____________________________________________________ my true and lawful attorney-in-fact for me and in my name, and in my behalf. My Agent shall have full power and aI, ____________________________________ ("Principal") maintaining an address at _______________________________________________ do hereby make and appoint ________________________________________ ("Ag___________________________ Address: _______________________________________ Phone:______________________ ILLINOIS DURABLE POWER OF ATTORNEY Effective Immediately KNOW ALL PERSONS BY THESE PRESENTS: later wish to do so. AGENT: By accepting or acting under the appointment, the agent assumes the fiduciary and other legal responsibilities of an agent. -3- Document Prepared by: Name: ______________stions about these powers, obtain competent legal advice. This document does not authorize anyone to make medical and other health-care decisions for you. You may revoke this power of attorney if you the power to sell, mortgage or dispose of your property. Any such action undertaken by your agent, within the scope of this power of attorney document, is legally binding upon you. If you have any queeeping. Before signing this document, consider its consequences. You ("principal") are providing another person ("agent") with the power to handle business and legal matters on your behalf, including tions included with the forms packages offered for sale, generally include state specific instructions. -2- CAUTION! PRINCIPAL: The Powers granted by this power of attorney document are broad and swte that this information is not intended as and is not a substitute for legal advice. Furthermore, this information is general information that is not state specific. Whenever appropriate, the instruc Power of Attorney 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. Please nopecially if 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 be legally binding upon the Grantor. The Grantor can revoke a Durable Power of Attorney at any time. A Durable Power of Attorney should always be notarized, even if your state does not require it, eshould be a competent adult. A Power 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 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. The Agent s This particular Form becomes effective immediately and remains in full force and effect even if the Principal (i.e. the Grantor) later becomes incapacitated. Note that the word "attorney" is not usedmpetent person (called the "Principal" or "Grantor") to authorize someone else (called the "Agent" or "Attorney-InFact") to act on his or her behalf, even if the Principal later becomes incapacitated.is subject to the Disclaimers and Terms of Use found at findlegalforms.com. -1- Information Durable Power of Attorney Effective Immediately A Durable Power of Attorney allows a natural "mentally" cot for you and should not be used without consulting with an attorney first. An Attorney should be consulted before negotiating any document with another party. [_] The purchase and use of these forms ent has the power to handle business and legal matters on the Principal's behalf. [_] These forms are not intended and are not a substitute for legal advice. These forms should only be a starting poiney-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 and sweeping, as the AgPrincipal 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 the Agent (or attornent's spouse or children, and the Notary should not be witnesses. [_] The name of the person who prepared the Power of Attorney should be entered at the top of the Power of Attorney document. [_] The l allow the Durable Power of Attorney to be recorded as a public record, if necessary. [_] Two witnesses need to sign the Power of Attorney. The witnesses should be competent adults. The Agent, the Agen if the Principal (i.e. the Grantor) becomes subsequently incapacitated. [_] The Principal (i.e. the person granting the power of Attorney) should sign the document before a Notary. Notarization wilation for Durable Power of Attorney Effective Immediately; (3) Durable Power of Attorney Effective Immediately [_] This Durable Power of Attorney becomes effective immediately and remains effective evInstructions & Checklist Illinois Durable Power of Attorney Effective Immediately [_] This package contains (1) Instructions & Checklist for Durable Power of Attorney Effective Immediately; (2) Inform IllinoisIllinois typed, printed, or stamped -5- who has produced ________________________________ as identification. _________________________________ Signature of person taking acknowledgment (Notary Public) _________________________________ Name______________ ) The foregoing instrument was acknowledged before me this _____ day of ____________________, ______ by __________________________ (name of Principal), who is personally known to me or ____________________________ Name: ___________________________________ City: __________________________________ State: ___________________________________ State of ILLINOIS ) ) ss County of __________ Signature: ___________________________________ Name: ___________________________________ City: __________________________________ State: ___________________________________ Witness Signature: _______ney at any time by providing written notice to my Agent. Signed on ________________ (date), at _______________________ (city), Illinois. ________________________________ Signature of Principal Witness 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 of Attorod faith on the authority of this document, without notice of such termination, shall be held harmless. Agent shall not be liable for losses resulting from judgment errors made in good faith. However,rty for any claims that arise -4- 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 gothis 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 the third pawith 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 copy of 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 ownership fected 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 on this art 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 not be afdly 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. If any prsonal 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 construed as broaout 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 authorized pefinancial 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 carrying ed 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 manage my ument 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 as providand 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 of this doc, Agent may not disclaim assets, to 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 Attorney claim 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. However 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. -3- 17. To diss, 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, excludingmy 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 creditorach 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 indirectly, to ift 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 the end of ent, 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 federal gther 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 directly or paremise 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 regard to whencome 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 negotiate, compronts. 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 or other ithe 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 estate agestocks, 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 interest in, in th 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 respect to , or draft of the United States of America, including U.S. Treasury Securities. 10. To have access to any safe deposit box, vault or other storage area owned or leased by me alone or in conjunction wiates, cashier checks, cash or vouchers payable to me by any person, firm, corporation or political entity; to perform any act necessary to deposit, -2- negotiate, sell or transfer any note, securityincluding, but not limited to, making deposits and withdrawals, negotiating or endorsing any checks or other instruments, obtaining bank statements, passbooks, drafts, warrants, money orders, certificerage 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 accounts, eiving 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 accounts, brokernmental 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 purpose of recuding, 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 connection with gov 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 program inclurance 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 policies. 8. To 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 deal with 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 possession; and thel 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 document, insave, 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 proper) deale 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 interest, to hd 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 documents of tit 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. 5. To receive, hold, possess and/or invest any anbts and obligations and such other instruments in writing of whatever kind and nature as may be. -1- 3. To request, ask, demand, sue and take any and all legal steps necessary to recover and collect, 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 and other dee documents, checks, drafts, letters of credit, stock certificates, proxies, warrants, commercial papers, withdrawal and deposit slips, certificates of deposit of, or investments with or through banksications, assignments, bills of sale or lading, bonds, contracts, covenants, conveyances, deeds, options, trust deeds, security agreements, leases, mortgages, notes, insurance policies, receipts, titler 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 limited to applAgent'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. 2. To ent 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 granted. My cquire 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 present. Ito 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 may later aerve for any reason, I appoint _____________________________________ maintaining an address at: _____________________________________________________ as my alternate or successor Agent, as necessary, ") 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 unable to s____________________________________ ("Principal") maintaining an address at _______________________________________________ do hereby make and appoint ________________________________________ ("Agent____________________ Address: _______________________________________ Phone:______________________ ILLINOIS DURABLE POWER OF ATTORNEY Effective upon Disability KNOW ALL PERSONS BY THESE PRESENTS: I, ish to do so. AGENT: By accepting or acting under the appointment, the agent assumes the fiduciary and other legal responsibilities of an agent. -3- Document Prepared by: Name: _____________________about these powers, obtain competent legal advice. This document does not authorize anyone to make medical and other health-care decisions for you. You may revoke this power of attorney if you later wer to sell, mortgage or dispose of your property. Any such action undertaken by your agent, within the scope of this power of attorney document, is legally binding upon you. If you have any questions Before signing this document, consider its consequences. You ("principal") are providing another person ("agent") with the power to handle business and legal matters on your behalf, including the powncluded with the forms packages offered for sale, generally include state specific instructions. -2- CAUTION! PRINCIPAL: The Powers granted by this power of attorney document are broad and sweeping. this information is not intended as and is not a substitute for legal advice. Furthermore, this information is general information that is not state specific. Whenever appropriate, the instructions in't require that a Durable Power of Attorney be witnessed, it is always a very good idea to do so. Two witnesses are necessary, if the Agent will deal with any real estate in Florida. Please note that difficult for any third party to challenge the validity of the Power of Attorney and will allow the Durable Power of Attorney to be recorded as a public record, if necessary. Although, some states dohe Agent. A Durable Power of Attorney should always be notarized, even if your state does not require it, especially if the Agent will be dealing with any real property. Notarization will make it morencipal becomes disabled or incompetent, an alternate Agent can be designated, at the time this Power of Attorney is signed, in the event the original Agent is unable to serve or continue to serve as tr of Attorney goes into effect, or the Agent undertakes the acts. The Principal can revoke a Durable Power of Attorney at any time. Since this Durable Power of Attorney takes effect only after the Prion undertaken by the Agent, within the scope of the Power of Attorney document, will be legally binding upon the Principal. This is especially important if the Principal is incapacitated when the Powencipal does not need to be a lawyer. Almost anyone can be appointed an attorney-in-fact by a power of attorney. A Power of Attorney is a "powerful" instrument and should be granted with care. Any actiicular Form becomes effective upon the disability or incapacity of the Principal. Note that the word "attorney" is not used here to mean "lawyer". The person acting as the attorney-in-fact for the Prion (called the "Principal" or "Principal") to authorize someone else (called the "Agent" or "AttorneyIn-Fact") to act on his or her behalf, even if the Principal later becomes incapacitated. This parte Disclaimers and Terms of Use found at findlegalforms.com -1- Information Durable Power of Attorney Effective upon Disability A Durable Power of Attorney allows a natural "mentally competent " pershould not be used without consulting with an attorney first. An Attorney should be consulted before negotiating a document with another party. [_] The purchase and use of these forms, is subject to thved, deleted (and initialed) or the words "no one" can be entered. [_] These forms are not intended and are not a substitute for legal advice. These forms should only be a starting point for you and s behalf. [_] This document offers the option of nominating an alternate Agent in the event that the first choice as Agent is unable to serve or continue to serve as the Agent. This section can be remo also be very careful in the selection of the Agent. The powers granted by this document are very broad and sweeping, as the Agent has the power to handle business and legal matters on the Principal's should have access to the original document as needed. [_] The Principal should be careful in instructing the Agent (or attorney-in-fact) as to the tasks the Agent should complete. The Grantor should name of the person who prepared the Power of Attorney should be entered at the top of the Power of Attorney document. [_] The Principal should keep the original document, as well as a copy. The Agent with any real estate in Florida. The witnesses should be adults. Generally, anyone related by blood or marriage to the Principal, the Agent or the Notary should not be a witness. [_] In Illinois, the public record, if necessary. [_] Although not always required, it is always a good idea to also have two witnesses sign the Power of Attorney. Two witnesses are necessary if the Agent will be dealingof the 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) 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 Instructions & Checklist Illinois Durable Power of Attorney Effective upon Disability [_] This package contains (1) Instructions & Checklist for Durable Power of Attorney Effective upon Disability; (2 IllinoisIllinois tion. _________________________________ Signature of person taking acknowledgment (Notary Public) _________________________________ Name typed, printed, or stamped -5- re me this _____ day of ____________________, ______ by __________________________ (name of Principal), who is personally known to me or who has produced ________________________________ as identifica____ City: __________________________________ State: ___________________________________ State of ILLINOIS ) ) ss County of ________________________ ) The foregoing instrument was acknowledged befo______________________ City: __________________________________ State: ___________________________________ Witness Signature: ___________________________________ Name: _____________________________________________ (date), at _______________________ (city), Illinois. ________________________________ Signature of Principal Witness Signature: ___________________________________ Name: _____________ good faith and/or willful misconduct, while acting under the authority of this Power of Attorney. I may revoke this Power of Attorney at any time by providing written notice to my Agent. Signed on __ion, shall be held harmless. -4- Agent shall not be liable for losses resulting from judgment errors made in good faith. However, Agent will be liable for breach of fiduciary duty, failure to act inance on this power of attorney. If this General Power of Attorney is terminated by operation of law, any person relying in good faith on the authority of this document, without notice of such terminats not effective as to a third party until the third party has actual knowledge of the revocation. I agree to indemnify the third party for any claims that arise against the third party because of relimy Agent; and/or (c) my assets to be subject to a general power of appointment by my Agent. Any third party who receives a copy of this document may act under it. Revocation of the power of attorney ie limited to the extent necessary to prevent (a) my income to be taxable to my Agent; (b) my Agent to have any rights or ownership with respect to any life insurance policies I may own on the life of e reasons for the use or issuance of this power-ofattorney or as to the disposition of any proceeds paid to my Agent based on this document. The powers granted to my Agent by this power-of-attorney arunder applicable law, then the remaining unaffected parts of the document shall still remain in full force and effect and not be affected by any partial invalidity. No person needs to inquire as to thghts, acts or powers are not intended to restrict or limit the definition or scope of powers granted herein in any manner. If any part of this document is held to be invalid, illegal or unenforceable hall provide an accounting for all funds handled and all acts performed as my Agent. This Power of Attorney shall be construed broadly as a General Power of Attorney. The listing of specific terms, rishall also be entitled to reasonable compensation for any services provided as my Agent If so requested by myself or any authorized personal representative or fiduciary acting on my behalf, my Agent ssources and affairs properly. My Agent shall be entitled to reimbursement of all reasonable expenses incurred as a result of carrying out any provision of this Power of Attorney. If desired, my Agent ty or incapacity. As used herein, "disability" or "incapacity" shall mean a lack of capacity to receive and evaluate information effectively, to communicate decisions, and/or to manage my financial re become effective immediately upon execution of this instrument. The rights, powers, and authority of this document shall remain in full force and effect thereafter until my death or until my disabiliitled, if the result is that the disclaimed assets pass directly or indirectly to my Agent or my Agent's estate. This General Power of Attorney and the rights, powers, and authority of my Agent shallnt), which might be transferred or distributed to me from any other person, estate, trust, or other entity, as may be appropriate. However, Agent may not disclaim assets, to -3- which I would be entansfer 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 disclaim any interest (subject to other provisions of this docume of my assets to discharge any of my Agent's legal obligations, including any obligations of support which my Agent may owe to others, excluding those whom I am legally obligated to support. 16. To tre 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 creditors, or the creditors of my Agent's estate, or (c) use anycifically authorized by this document, (a) gift, appoint, assign or designate any of my assets, interests or rights, directly or indirectly, to my Agent, my Agent's estate, my Agent's creditors, or thfederal gift tax annual exclusion amount in any one calendar year, and this annual right shall be non-cumulative and shall lapse at the end of each calendar year. However, my Agent may not, unless spe 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 federal gift tax annual exclusion, shall not exceed in value the rwise, and if necessary, to file any state and federal gift tax returns and documents. Gifts to minors may be made to the minor directly or parent, guardian or close friend of the minor or pursuant togifts and charitable contributions of my real, personal, tangible or intangible property, to such persons or organizations without regard to whether such gifts are a part of my estate planning or otheents; to obtain or provide information to and from any agency, including governmental agencies, relating to tax matters and to negotiate, compromise or settle any matter with such agency. 15. To make or file any documents with any federal, state, local or other governmental body, including, but not limited to, federal, state, local or other income and tax returns and necessary and/or related documss assistance as may be appropriate, including but not limited to, attorneys, accountants, investment professionals, brokers and real estate agents. 14. To prepare, or cause to be prepared, sign, and/ther investments. 12. To maintain and/or operate any business that I currently own or have an interest in or may own or have an interest in, in the future. 13. To employ any professional and/or busine and to examine, remove, keep or otherwise dispose of the contents. 11. To exercise any and all rights, including proxy rights, with respect to stocks, bonds, debentures, commodities, options or any oasury Securities. -2- 10. To have access to any safe deposit box, vault or other storage area owned or leased by me alone or in conjunction with any other person, including access to their contents,any person, firm, corporation or political entity; to perform any act necessary to deposit, negotiate, sell or transfer any note, security, or draft of the United States of America, including U.S. Trerawals, negotiating or endorsing any checks or other instruments, obtaining bank statements, passbooks, drafts, warrants, money orders, certificates, cashier checks, cash or vouchers payable to me by lar accounts with financial institutions; to conduct any business with any banking or financial institution with respect to any of my accounts, including, but not limited to, making deposits and withdd/or close bank accounts, including, but not limited to, checking accounts, savings accounts, certificates of deposit, investment accounts, brokerage accounts, retirement plan accounts, and other simil, military and social security benefits), and to appoint anyone, including my Agent, to act as my "Representative Payee" for the purpose of receiving Social Security benefits. 9. To open, maintain an to prepare applications, provide information, and perform any other reasonable request by any government or its agencies in connection with governmental benefits (including but not limited to, medica recover all payments I receive from any annuity, pension, retirement benefits, retirement plans, insurance benefits and government program including, but not limited to, Social Security and Medicare;ing life insurance upon my life or the life of any other appropriate person and to make any elections and disclaimers under such policies. 8. To receive, deposit, hold, demand, deal with and/or sue to receive all monies which may become due and owing to me by reason of such transaction. 7. To apply for, purchase, maintain and/or deal with insurance and annuity contracts, insurance policies, includ 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 possession; and the right to ask for, demand, sue for, collect, recover andonal property or asset whatsoever, tangible or intangible (now owned or acquired in the future by me) and to execute any necessary document, instrument or deed for such transactions. This includes the, sell, mortgage, improve, repair, exchange, invest, reinvest and in any other manner (on such terms and at prices my Agent may deem proper) deal with all, any part or any interest in any real or pers, 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 interest, to have, or use. 6. To maintain, manage, insure, lease, rentpapers, checks, drafts, causes of action, bequests, deposits, notes, interests, dividends, certificates of deposit, any and all documents of title and demands whatsoever, whether agreed to or disputedettle any claim, against me or asserted on my behalf against any other person or entity. -1- 5. To receive, hold, possess and/or invest any and all sums of money, accounts, debts, bonds, commercial g 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 collect any amount or debt owed to me. 4. To adjust, compromise and sher institutions, proofs of loss, evidences of debts, releases, and satisfaction of mortgages, lien, judgments, security agreements and other debts and obligations and such other instruments in writinrtificates, proxies, warrants, commercial papers, withdrawal and deposit slips, certificates of deposit of, or investments with or through banks, savings and loan, brokers, mutual fund companies or otontracts, covenants, conveyances, deeds, options, trust deeds, security agreements, leases, mortgages, notes, insurance policies, receipts, title documents, checks, drafts, letters of credit, stock cerse and execute any written agreement and document necessary to enter into any such contract and/or agreement, including but not limited to applications, assignments, bills of sale or lading, bonds, cimited 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. 2. To enter into binding contracts on my behalf and to sign, endo Agent's substitute or substitutes, shall lawfully do or cause to be done by virtue of this power of attorney and the rights hereby granted. My Agent's powers and authority shall include, but not be lm, transaction, thing, business, property, real or personal, tangible or intangible, or matter whatsoever as I could do if personally present. I hereby ratify and confirm all acts that my Agent, or myy Agent shall have full power and authority to perform any act, power, duty, legal right or obligation whatsoever that I now have or may later acquire in connection with or relating to any person, ite______________________________ ("Agent") maintaining an address at: _____________________________________________________ my true and lawful attorney-in-fact for me and in my name, and in my behalf. MNOW ALL PERSONS BY THESE PRESENTS: I, ____________________________________ ("Principal") maintaining an address at _______________________________________________ do hereby make and appoint __________n agent. -3- Document Prepared by: Name: _________________________________________ Address: _______________________________________ Phone:______________________ ILLINOIS GENERAL POWER OF ATTORNEY Ks for you. You may revoke this power of attorney if you later wish to do so. AGENT: By accepting or acting under the appointment, the agent assumes the fiduciary and other legal responsibilities of acument, is legally binding upon you. If you have any questions about these powers, obtain competent legal advice. This document does not authorize anyone to make medical and other health-care decisionle business and legal matters on your behalf, including the power to sell, mortgage or dispose of your property. Any such action undertaken by your agent, within the scope of this power of attorney donted by this power of attorney document are broad and sweeping. Before signing this document, consider its consequences. You ("principal") are providing another person ("agent") with the power to handis not state specific. Whenever appropriate, the instructions included with the forms packages offered for sale, generally include state specific instructions. -2- CAUTION! PRINCIPAL: The Powers graantor later becomes disabled or incapacitated. Please note that this information is not intended as and is not a substitute for legal advice. Furthermore, this information is general information that y be witnessed, it is always a very good idea to do so. Another type of Power of Attorney, called a Durable Power of Attorneys (available at findlegalforms.com as well), stays in effect even if the Gr the validity of the Power of Attorney and will allow the General Power of Attorney to be recorded as a public record, if necessary. Although, some states don't require that a General Power of Attorned always be notarized, even if your state does not require it, especially if the Agent will be dealing with any real property. Notarization will make it more difficult for any third party to challengee Agent, within the scope of the Power of Attorney document, will be legally binding upon the Grantor. The Grantor can revoke a General Power of Attorney at any time. A General Power of Attorney shoulappointed an Attorney-In-Fact by a power of attorney. The Agent should be a competent adult. A Power of Attorney is a "powerful" instrument and should be granted with care. Any action undertaken by thabled or incapacitated. Note that the word "attorney" is not used 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 the "Agent" or "Attorney-InFact") to act on his or her behalf. This particular Form becomes effective immediately and remains effective until the death of the Grantor or until the Grantor becomes disalforms.com -1- Information General Power of Attorney A General Power of Attorney allows a natural "mentally" competent person (called the "Principal" or "Grantor") to authorize someone else (calledorney first. An Attorney should be consulted before negotiating any document with another party. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegrincipal's behalf. [_] These forms are not intended and are not a substitute for legal advice. These forms should only be a starting point for you and should not be used without consulting with an atttor should also be very careful in the selection of the Agent. The powers granted by this document are very broad and sweeping, as the Agent has the power to handle business and legal matters on the P The Agent should have access to the original document as needed. [_] The Principal should be careful in instructing the Agent (or attorney-in-fact) as to the tasks the Agent should complete. The Graninois, the name of the person who prepared the Power of Attorney should be entered at the top of the Power of Attorney document. [_] The Principal should keep the original document, as well as a copy.be dealing with any real estate in Florida. The witnesses should be adults. Generally, anyone related by blood or marriage to the Principal, the Agent or the Notary should not be a witness. [_] In Illorded as a public record, if necessary. [_] Although not always required, it is always a good idea to also have two witnesses sign the Power of Attorney. Two witnesses are necessary if the Agent will ] The Principal (i.e. the person granting the Power of Attorney; sometimes called the Grantor) should sign the document before a Notary. Notarization will allow the General Power of Attorney to be recneral Power of Attorney [_] This General Power of Attorney becomes effective immediately and remains effective until the death of the Grantor or until the Grantor becomes disabled or incapacitated. [_Instructions & Checklist Illinois General Power of Attorney [_] This package contains (1) Instructions & Checklist for General Power of Attorney; (2) Information for General Power of Attorney; (3) Ge IllinoisIllinois __________________ as identification. _________________________________ Signature of person taking acknowledgment (Notary Public) _________________________________ Name typed, printed, or stamped -4-instrument was acknowledged before me this _____ day of ____________________, ______ by __________________________ (name of Principal), who is personally known to me or who has produced ______________re of person taking acknowledgment (Notary Public) _________________________________ Name typed, printed, or stamped -3- State of ILLINOIS ) ) ss County of ________________________ ) The foregoing _____ by __________________________ (name of Principal), who is personally known to me or who has produced ________________________________ as identification. _________________________________ Signatu_ State: ___________________________________ State of ILLINOIS ) ) ss County of ________________________ ) The foregoing instrument was acknowledged before me this _____ day of ____________________, _____________________ State: ___________________________________ Witness Signature: ___________________________________ Name: ___________________________________ City: __________________________________________ Signature of Father ________________________________ Signature of Mother Witness Signature: ___________________________________ Name: ___________________________________ City: ______________rney before the expiration date at any time by providing written notice to the Attorney-in-Fact. Signed on ________________ (date), at _______________________ (city), Illinois. _______________________s terminated by operation of law, any person relying in good faith on the authority of this document, without notice of such termination, shall be held harmless. -2- We may revoke this Power of Attos actual knowledge of the revocation. We agree to indemnify the third party for any claims that arise against the third party because of reliance on this power of attorney. If this Power of Attorney icted by any partial invalidity. Any third party who receives a 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 hat 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 not be affed the rights hereby granted. The Attorney-in-Fact shall be entitled to reimbursement of all reasonable expenses incurred as a result of carrying out any provision of this Power of Attorney. If any part and understand the full import of this grant of powers to the Attorney-in-Fact named herein. We hereby ratify and confirm all acts by the Attorney-in-Fact done by virtue of this power of attorney anldren. This power of attorney shall be in effect from _______________ to _______________ ("expiration date"). By signing here, we indicate that we are fully informed as to the contents of this documenld or withdraw life sustaining procedures for any child/children; (ii) have the power to consent to the marriage of our child/children; (iii) have the power to consent to the adoption of our child/chiwaivers, insurance documents, claims, agreements, contracts and legal documents. Notwithstanding other provisions in this Power of Attorney, Attorney-in-Fact shall not (i) have the authority to withhoth or other type of insurance company. 6. Endorse and execute any documents necessary for the performance of the powers granted by this document, including but not limited to consent forms, releases, other person or entity. 5. Apply for, purchase, maintain and/or deal with any health and other insurance for our child/children and to make and file any medical or other type of claim against any healatters. 4. Request, ask, demand, sue and take any and all legal steps necessary on behalf of our child/children and to adjust, compromise and settle any claim, our child/children may have against any ional facility. -1- 3. Maintain the customary living standard of the child/children, including, but not limited to, provisions of living quarters, food, clothing, entertainment and other customary m, schools and extracurricular activities; review any school records of the child/children; allow our child/children to participate in activities and events offered by any group, organization or educat-ray examination, performance of operations, diagnostic and other procedures. 2. Determine the education of our child/children and to register and enroll our child/children in any educational programstal or other health authorities incident to the provision of medical, surgical or dental care to our child/children. Health care shall include but not be limited to the administration of anesthesia, Xon whose services may be needed for such health care; review and if necessary disclose the contents of any medical records; execute any consent, release or waiver of liability required by medical, denncluding, but not limited to, the powers to: 1. Provide for, approve, authorize and decline any health care at any hospital or other institution; employ any physicians, dentists, nurses, or other persct shall have the power and authority to act entirely in loco parentis and to do all acts necessary or desirable for maintaining the health, education, and welfare of our above named child/children, i________________________________ born on __________ Name: _________________________________ born on __________ Name: _________________________________ born on __________ The above named Attorney-in-Fachild/children: Name: _________________________________ born on __________ Name: _________________________________ born on __________ Name: _________________________________ born on __________ Name: _ng an address at: _____________________________________________________ as our true and lawful agent and attorney-in-fact for us and in our name, and in our behalf to act as the guardian of our minor red to as "Parents" or "Principals", maintaining an address at: ________________________________________ hereby make and appoint ________________________________________ ("Attorney-in-Fact") maintainiY FOR THE CARE OF CHILDREN KNOW ALL PERSONS BY THESE PRESENTS: We ______________________________________________________ ("Father") and ______________________________________ ("Mother"), jointly referesponsibilities of an agent. -3- Document Prepared by: Name: _________________________________________ Address: _______________________________________ Phone:______________________ POWER OF ATTORNE competent legal advice. You may revoke this power of attorney at any time. ATTORNEY-IN-FACT: By accepting or acting under the appointment, the Attorney-in-Fact assumes the fiduciary and other legal rild/children. Any such action undertaken by the Attorney-in-Fact, within the scope of this power of attorney document, is legally binding upon you. If you have any questions about these powers, obtainigning this document, consider its consequences. You ("Parents") are providing another person ("Attorney-in-Fact") with the power to handle and control the care, custody, health and welfare of your choffered for sale, generally include state specific instructions. -2- CAUTION! PARENTS: The powers granted by this Power of Attorney for the Care of Children document are broad and sweeping. Before sd as and is not a substitute for legal advice. Furthermore, this information is general information that is not state specific. Whenever appropriate, the instructions included with the forms packages e validity of the Power of Attorney. Although, some states don't require that a Power of Attorney be witnessed, it is always a very good idea to do so. Please note that this information is not intendeon date. The Power of Attorney for the Care of Children should always be notarized, even if your state does not require it. Notarization will make it more difficult for any third party to challenge thtorney-in-Fact should do. Although the Power of Attorney for the Care of Children has a beginning and an "end/expiration" date, the Parents can revoke the document at any time even before the expiratinted by this document are very broad and sweeping and the children are being entrusted to the Attorney-in-Fact. The Parents should also be careful in instructing the Attorney-in-Fact as to what the Atso generally feel more comfortable dealing with an Attorney-inFact who can provide this type of document. The Parents should be very careful in the selection of the Attorney-in-Fact, as the powers grato better deal with any types of emergency involving the children and can avoid potential problems when, for example, arranging for medical, dental or any other type of care. Medical personnel will al by this instrument are very broad. Parents are basically giving temporary custody of the children to the Attorney-infact. By having this type of document available, the Attorney-in-Fact will be able ake decisions for the children in place of the parents, including health care, education and welfare decisions. This can be useful if the parent will be absent for a period of time. The powers grantedthe Attorney-in-Fact for the Parents or the children does not need to be a lawyer. Almost anyone can be appointed an Attorney-in-Fact by a power of attorney. This form allows the Attorney-in-Fact to mlled the "Principals" or "Grantors") to appoint another person to act as their Attorney-in-Fact to care for their children. The word "attorney" is not used here to mean "lawyer". The person acting as essary to allow someone else to provide for the care of your children, a Power of Attorney for the Care of Children form can be used. This document allows parents of one or more children (sometimes ca[_] The purchase and use of these forms, is subject to the Disclaimers and Terms of Use found at findlegalforms.com -1- Information Power of Attorney for the Care of Children Whenever it becomes necping. [_] These forms are not intended and are not a substitute for legal advice. These forms should only be a starting point for you and should not be used without consulting with an attorney first. be careful giving instructions to the Attorney-in-Fact. The Parents should also be very careful in the selection of the Attorney-in-Fact, as the powers granted by this document are very broad and sweect or Notary should not be a witness. [_] In Illinois, the name of the person who prepared the Power of Attorney should be entered at the top of the Power of Attorney document. [_] The Parents should required, it is always a good idea to also have two witnesses sign the Power of Attorney. The witnesses should be adults. Generally, anyone related by blood or marriage to the Parents, Attorney-in-Fahould keep a copy of the Power of Attorney for the Care of Children document for their records. [_] At least one witness should sign the Power of Attorney for the Care of Children. Although not alwaysthe Power of Attorney for the Care of Children document before a Notary. [_] The original Power of Attorney for the Care of Children document should be given to the Attorney-in-Fact. [_] The Parents s(3) additional useful information about Power of Attorney for the Care of Children documents. [_] Both Parents need to sign the Power of Attorney for the Care of Children. [_] The Parents should sign Instructions & Checklist Illinois Power of Attorney for the Care of Children [_]] This package contains a (1) Power of Attorney for the Care of Children; (2) simple instructions plus a checklist; and IllinoisIllinois ______________ _____________________________________________________ (Witness Signature) Print Name: ___________________________________________ declarant's death, or directly financially responsible for declarant's medical care. _____________________________________________________ (Witness Signature) Print Name: _____________________________o any portion of the estate of the declarant according to the laws of intestate succession or, to the best of my knowledge and belief, under any will of declarant or other instrument taking effect at declaration as a witness in the presence of the declarant. I did not sign the declarant's signature above for or at the direction of the declarant. At the date of this instrument, I am not entitled telieve him or her to be of sound mind. I saw the declarant sign the declaration in my presence (or the declarant acknowledged in my presence that he or she had signed the declaration) and I signed the______________________________________________________________ City, County and State of Residence ___________________________________________________ The declarant is personally known to me and I bation shall be honored by my family and physician as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences from such refusal. Signed: ____________sary by my attending physician to provide me with comfort care. In the absence of my ability to give directions regarding the use of such death delaying procedures, it is my intention that this declarng the dying process be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication, sustenance, or the performance of any medical procedure deemed necesndition by my attending physician who has personally examined me and has determined that my death is imminent except for death delaying procedures, I direct that such procedures which would only proloily make known my desires that my moment of death shall not be artificially postponed. If at any time I should have an incurable and irreversible injury, disease, or illness judged to be a terminal co This declaration is made this __________ day of _________________ , _________________(month, year). I, ___________________________________________________, being of sound mind, willfully and voluntarf 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 Living Will DECLARATIONattorney 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 osubstitute 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 an mplied 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 erson for failure to act upon a revocation made pursuant to this Section unless that person has actual knowledge of the revocation. (Source: P.A. 85-860.) [_] These forms are provided "as is" and no istructions ­ Page 3 medical record the time and date when and the place where he or she received notification of the revocation. (c) There shall be no criminal or civil liability on the part of any peffective upon communication to the attending physician by the declarant or by another who witnessed the revocation. The attending physician shall record in the patient's Living Will Information & Inon of the intent to revoke the declaration, in the presence of a witness 18 years of age or older who signs and dates a writing confirming that such expression of intent was made. (b) A revocation is icating intention to cancel; (2) By a written revocation of the declaration signed and dated by the declarant or person acting at the direction of the declarant; or (3) By a oral or any other expressie by the declarant, without regard to declarant's mental or physical condition, by any of the following methods: (1) By being obliterated, burnt, torn or otherwise destroyed or defaced in a manner indthe circumstances, he is immune from civil or criminal liability that otherwise might be incurred. (Source: P.A. 85-860.) 755 ILCS 35/5) Sec. 5. Revocation. (a) A declaration may be revoked at any tim terminal condition under this Section is presumed to be acting in good faith. Unless it is alleged and proved that his action violated the standard of reasonable professional care and judgment under al condition, the attending physician who knows of a declaration shall record the determination and the terms of the declaration in the declarant's medical record. A physician who records in writing ahe necessity of obtaining a court order to do so, and (3) any member of the patient's family. 755 ILCS 35/4) Sec. 4. Recording of a Terminal Condition. Upon determining that the declarant has a terminfectuation of the patient's declaration. The order of priority is as follows: (1) any person authorized by the patient to make such arrangements, (2) a guardian of the person of the patient, without t priority, as set forth in this subsection, who is available, able, and willing to make arrangements for the transfer of the patient and the appropriate medical records to another physician for the efysician is unwilling to comply with its provisions and the patient is at any time not able to initiate the transfer, then the attending physician shall without delay notify the person with the highest the physician is unwilling to comply with its provisions and the patient is able, it is the patient's responsibility to initiate the transfer to another physician of the patient's choosing. If the ph, or copy of the declaration, a part of the patient's medical records. If the physician is at any time unwilling to comply with its provisions, the physician shall promptly so advise the declarant. Ifide the declaration to the physician and to ask the attending physician whether he or she is willing to comply with its provisions. An attending physician who is so notified shall make the declaration delaying procedures. (d) If the patient is able, it shall be the responsibility of the patient to provide for notification to his or her attending physician of the existence of a declaration, to provn shall be given no force and effect as long as in the opinion of the attending physician it is possible that the fetus could develop to the point of live birth with the continued application of death declarant, or another at the declarant's direction, and witnessed by 2 individuals 18 years of age or older. (c) The declaration of a qualified patient diagnosed as pregnant by the attending physiciaa document directing that if he is suffering from a terminal condition, then death delaying procedures shall not be utilized for the prolongation of his life. (b) The declaration must be signed by the sound mind and having reached the age of majority or having obtained the status of an emancipated person pursuant to the "Emancipation of Mature Minors Act", as now or hereafter amended, may execute eath is imminent and the application of death delaying procedures serves only to prolong the dying process. (Source: P.A. 85-860.) (755 ILCS 35/3) Sec. 3. Execution of a Document. (a) An individual ofdelaying procedures as long as he or she is able to do so. (h) "Terminal condition" means an incurable and irreversible condition which is such that Living Will Information & Instructions ­ Page 2 died in writing to be afflicted with a terminal condition by his or her attending physician who has personally examined the patient. A qualified patient has the right to make decisions regarding death eans a person licensed to practice medicine in all its branches. (g) "Qualified patient" means a patient who has executed a declaration in accordance with this Act and who has been diagnosed and verif. (e) "Person" means an individual, corporation, business trust, estate, trust, partnership, association, government, governmental subdivision or agency, or any other legal entity. (f) ) "Physician" mhall not be withdrawn or withheld from a qualified patient if the withdrawal or withholding would result in death solely from dehydration or starvation rather than from the existing terminal conditionthis Act does not affect the responsibility of the attending physician or other health care provider to provide treatment for a patient's comfort care or alleviation of pain. Nutrition and hydration silation, artificial kidney treatments, intravenous feeding or medication, blood transfusions, tube feeding and other procedures of greater or lesser magnitude that serve only to delay death. However, fied patient, in the judgement of the attending physician would serve only to postpone the moment of death. In appropriate circumstances, such procedures include, but are not limited to, assisted venttate to administer health care in the ordinary course of business or practice of a profession. (d) "Death delaying procedure" means any medical procedure or intervention which, when applied to a qualioluntarily executed by the declarant in accordance with the requirements of Section 3. (c) "Health-care provider" means a person who is licensed, certified or otherwise authorized by the law of this Sician" means the physician selected by, or assigned to, the patient who has primary responsibility for the treatment and care of the patient. (b) "Declaration" means a witnessed document in writing, vinstructing his or her physician to withhold or withdraw death delaying procedures in the event of a terminal condition. (Source: P.A. 85-860.) (755 ILCS 35/2) Sec. 2. Definitions: (a) "Attending physe no longer able to participate actively in decisions about themselves, the legislature hereby declares that the laws of this State shall recognize the right of a person to make a written declaration ical care, including the decision to have death delaying procedures withheld or withdrawn in instances of a terminal condition. In order that the rights of patients may be respected even after they aris Statutes relating to Living Wills. (755 ILCS 35/1) Sec. 1. Purpose. The legislature finds that persons have the fundamental right to control the decisions relating to the rendering of their own med) is based on Chapter 755 Section 35 of the Illinois Compiled Statutes also known as the Illinois Living Will Act (755 ILCS 35/). For your convenience, we have included useful excerpts from the Illino Instruction for Illinois Declaration to Physicians (Illinois Living Will); (2) Illinois Declaration to Physicians (Illinois Living Will). This Illinois Declaration to Physicians (Illinois Living Will______________________________ (Successor agent) _________________________________ (Principal) Information and Instructions Illinois Living Will Declaration This package contains (1) Information andgnature of my agent (and successors) are correct. _________________________________ (Principal) _________________________________ (Successor agent) _________________________________ (Principal) ___of attorney, you must complete the certification opposite the signatures of the agents.) Specimen signatures of agent (and successors) _________________________________ (Agent) I certify that the si__________________________ (witness) (You may, but are not required to, request your agent and successor agents to provide specimen signatures below. If you include specimen signatures in this power principal has had an opportunity to read the above form and has signed the form or acknowledged his or her signature or mark on the form in my presence. _______________________________ Residing at __ of this grant of powers to my agent. Illinois Statutory Short Form Power of Attorney for Health Care Page 4 Signed: _______________________________________________________________ (principal) The I nominate the agent acting under this power of attorney as such guardian, to serve without bond or security. 7. I am fully informed as to all the contents of this form and understand the full importourt finds that such appointment will serve your best interests and welfare. Strike out paragraph 6 if you do not want your agent to act as guardian.) 6. If a guardian of my person is to be appointed,dian of your person, in the event a court decides that one should be appointed, you may, but are not required to, do so by retaining the following paragraph. The court will appoint your agent if the cncompetent or disabled person or the person is unable to give prompt and intelligent consideration to health care matters, as certified by a licensed physician. (If you wish to name your agent as guar________________________________________________________________ For purposes of this paragraph 5, a person shall be considered to be incompetent if and while the person is a minor or an adjudicated ithe order named) as successors to such agent: ________________________________________________________________________ ________________________________________________________________________ ________ing paragraph.) 5. If any agent named by me shall die, become incompetent, resign, refuse to accept the office of agent or be unavailable, I name the following (each to act alone and successively, in rt determination of your disability, when you want this power to terminate prior to your death.) (If you wish to name successor agents, insert the names and addresses of such successors in the followfect) 4. ( ) This power of attorney shall terminate on ______________________________ _____________________________________________________________________ (Insert a future date or event, such as cou_________________________________________________________ (insert a future date or event during your lifetime, such as court determination of your disability, when you want this power to first take ef on the beginning date or duration is made by initialing and completing either or both of the following:) 3. ( ) This power of attorney shall become effective ___________________________ _____________ attorney will become effective at the time this power is signed and will continue until your death, and beyond if anatomical gift, autopsy or disposition of remains is authorized, unless a limitationy you in the manner provided in section 4-6 of the Illinois "powers of attorney for health care law" (see the back of this form). Absent amendment or revocation, the authority granted in this power ofI have for recovery or the cost of the procedures. Initialed _____________ Illinois Statutory Short Form Power of Attorney for Health Care Page 3 (This power of attorney may be amended or revoked bma, I want life-sustaining treatment to be withheld or discontinued. Initialed _____________ I want my life to be prolonged to the greatest extent possible without regard to my condition, the chances ed unless I am in a coma which my attending physician believes to be irreversible, in accordance with reasonable medical standards at the time of reference. If and when I have suffered irreversible coble extension of my life in making decisions concerning life-sustaining treatment. Initialed _____________ I want my life to be prolonged and I want life-sustaining treatment to be provided or continuntinued if my agent believes the burdens of the treatment outweigh the expected benefits. I want my agent to consider the relief of suffering, the expense involved and the quality as well as the possigree with one of these statements, you may initial that statement; but do not initial more than one): I do not want my life to be prolonged nor do I want life-sustaining treatment to be provided or cois of particular importance. For your convenience in dealing with that subject, some general statements concerning the withholding or removal of life-sustaining treatment are set forth below. If you astitution, etc.): _____________________________________________________________________ _____________________________________________________________________ (The subject of life-sustaining treatment consistent with your religious beliefs or unacceptable to you for any other reason, such as blood transfusion, electro-convulsive therapy, amputation, psychosurgery, voluntary admission to a mental inn life-sustaining measures should be withheld; a direction to continue food and fluids or life-sustaining treatment in all events; or instructions to refuse any specific types of treatment that are inhall not include the following powers or shall be subject to the following rules or limitations (here you may include any specific limitations you deem appropriate, such as: your own definition of whet's powers or prescribe special rules or limit the power to make an anatomical gift, authorize autopsy or dispose of remains, you may do so in the following paragraphs.) 2. The powers granted above sluding withdrawal of food and water and other life-sustaining measures, if your agent believes such action would be consistent with your intent and desires. If you wish to limit the scope of your agen Page 2 (The above grant of power is intended to be as broad as possible so that your agent will have authority to make any decision you could make to obtain or terminate any type of health care, incific organs: __________________________________________________ ______________________________________________________________________ Illinois Statutory Short Form Power of Attorney for Health Care orize an autopsy and direct the disposition of my remains. Effective upon my death, my agent has the full power to make an anatomical gift of the following (initial one): ______ Any organ: ______ Specen though my death may ensue. My agent shall have the same access to my medical records that I have, including the right to disclose the contents to others. My agent shall also have full power to authto make any and all decisions for me concerning my personal care, medical treatment, hospitalization and health care and to require, withhold or withdraw any type of medical treatment or procedure, ev_____________________________________________________________ (insert name and address of agent) as my attorney- in- fact (my "agent") to act for me and in my name (in any way I could act in person) made this __________ day of___________________(month, year). 1. I, __________________________________________________________________ (insert name and address of principal) hereby appoint: __________ts the use of any different form of power of attorney you may desire. If there is anything about this form that you do not understand, you should ask a lawyer to explain it to you.) POWER OF ATTORNEY ies for violating the law are explained more fully in sections 4-5, 4-6, 4-9 and 4-10(b) of the Illinois "Powers of Attorney for Health Care Law" of which this form is a part. That law expressly permi terminates it, your agent may exercise the powers given here throughout your lifetime, even after you become disabled. The powers you give your agent, your right to revoke those powers and the penaltot co-agents, and no health care provider may be named. Unless you expressly limit the duration of this power in the manner provided below, until you revoke this power or a court acting on your behalfipts, disbursements and significant actions taken as agent. A court can take away powers of your agent if it finds the agent is not acting properly. You may name successor agents under this form but n a duty on your agent to exercise granted powers; but when powers are exercised, your agent will have to use due care to act for your benefit and in accordance with this form and keep a record of receithdraw any type of personal care or medical treatment for any physical or mental condition and to admit you to or discharge you from any hospital, home or other institution. This form does not imposeh Care (NOTICE: the purpose of this power of attorney is to give the person you designate (your "agent") broad powers to make health care decisions for you, including power to require, consent to or wd with a tax professional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Illinois Statutory Short Form Power of Attorney for Healts 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 document should be discussevice. 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 to make sure it fitbeen 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 legal and/or tax ade 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 implied or express warranties have Illinois Advance Health Care Directive This package contains both an Illinois Power of Attorney for Health Care and an Illinois Living Will. Together these forms are also sometimes known as an Advanc Illinois