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Indiana d, printed, or stamped -5- as produced ________________________________ as identification. _________________________________ Signature of person taking acknowledgment (Notary Public) _________________________________ Name type_________ ) The foregoing instrument was acknowledged before me this _____ day of ____________________, ______ by __________________________ (name of Principal), who is personally known to me or who h________________________ Name: ___________________________________ City: __________________________________ State: ___________________________________ State of INDIANA ) ) ss County of _______________nature: ___________________________________ Name: ___________________________________ City: __________________________________ State: ___________________________________ Witness Signature: ___________ at any time by providing written notice to my Agent. Signed on ________________ (date), at _______________________ (city), Indiana. ________________________________ Signature of Principal Witness Sigent 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 Attorneyfaith 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, Ag 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 good s 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 partyh 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 thiument. 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 witted 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 doc 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 affec 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 partnal 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 broadly 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 persoancial 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 outby 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 finnt 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 provided 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 documegent 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 andim 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, Aose 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 disclaor 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, excluding thAgent, 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 creditors, 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 my 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 each 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 giftr 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 parent,e 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 whetheme 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, compromis. 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 inco 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 agentscks, 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 theany 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 stor 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 with s, 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, security, oluding, but not limited to, making deposits and withdrawals, negotiating or endorsing any checks or other instruments, obtaining bank statements, passbooks, drafts, warrants, money orders, certificatege 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, incing 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, brokeramental 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 receivng, 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 governceive, 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 includince 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 reght 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 insurament 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 the riith 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, instru, 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) deal wand 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 havell 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 title y 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 and a 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 anavings 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 debtsocuments, checks, drafts, letters of credit, stock certificates, proxies, warrants, commercial papers, withdrawal and deposit slips, certificates of deposit of, or investments with or through banks, stions, assignments, bills of sale or lading, bonds, contracts, covenants, conveyances, deeds, options, trust deeds, security agreements, leases, mortgages, notes, insurance policies, receipts, title dinto 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 applicant'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 enter reby 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 Ageire 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. I heserve 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 acque for any reason, I appoint _____________________________________ maintaining an address at: _____________________________________________________ as my alternate or successor Agent, as necessary, to 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 serv_________________________________ ("Principal") maintaining an address at _______________________________________________ do hereby make and appoint ________________________________________ ("Agent") __________________ Address: _______________________________________ Phone:______________________ INDIANA DURABLE POWER OF ATTORNEY Effective upon Disability KNOW ALL PERSONS BY THESE PRESENTS: I, ___h 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: _______________________out 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 wis 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 abefore 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 powerluded 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. Bhis 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 inct 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 tifficult 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 don' 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 more dipal 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 theof 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 Princ 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 Power ipal 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 actionular 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 Princ (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 particDisclaimers 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 " personuld 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 the d, 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 shoehalf. [_] 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 removelso 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 bhould 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 aame 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 swith 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 Indiana, the npublic 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 dealing f 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 oInstructions & Checklist Indiana Durable Power of Attorney Effective upon Disability [_] This package contains (1) Instructions & Checklist for Durable Power of Attorney Effective upon Disability; (2) IndianaIndiana of which the person(s) acted, executed the instrument. WITNESS my hand and official seal. Signature __________________________________ (Seal) t and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf________________________________ ___________, personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrumen__________ before me, (here insert name and title of the officer), personally appeared ________________________________________________________________________ ________________________________________________ Names of institutions/individuals who have been provided a copy of this revocation: Notary Acknowledgment State of __________________________ County of ________________________ ) ) ss ) On ______ State:_________________________ Witness Signature:__________________ Date: ___________________________ Name: ___________________________ City: _________________________ State:_________________ ___________________ (date). _____________________________ Principal Witness Signature:__________________ Date: ___________________________ Name: ___________________________ City: ___________________ artificial life sustaining procedures is revoked and withdrawn and this document provides notice of such revocation. IN WITNESS WHEREOF, I have signed this Health Care Power of Attorney Revocation on______________________________ (title of document(s)) dated __________________ and all power and authority granted thereby including powers for making health care decisions on my behalf and concerningRevocation I, ___________________________________ (Principal) maintaining an address at __________________________________________________ (address of Principal), hereby revoke my ____________________ion that is not state specific. Whenever appropriate, the instructions included with the forms packages offered for sale, generally include state specific instructions. Health Care Power of Attorney revoked. This revocation becomes effective immediately. Please note that this information is not intended as and is not a substitute for legal advice. Furthermore, this information is general informate Power of Attorney Revocation is used by the Grantor to give notice that a previously granted Health Care Power of Attorney (sometimes referred to as a Living Will or Health Care Directive) has been alth Care Power of Attorney Revocation If the Grantor of a Health Care Power of Attorney decides to revoke the document, it is almost always required that the revocation be in writing. The Health Carfor you and should not be used without consulting with an attorney first. The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Information Hetify both. These forms are not intended and are not a substitute for legal advice. Laws are different from state to state and may change from time to time. These forms should only be a starting point e revocation document. If more than one document is being revoked, then each document needs to be identified i.e. if you are revoking a Health Care Power of Attorney and a Living Will, be sure to idenpies of the Health Care Power of Attorney so as to avoid any questions about the revocation or its effectiveness. The exact full title of the document(s) that you are revoking should be inserted in thon. In the event the original power of attorney was filed publicly (i.e. recorded), then the notice of revocation should also be filed publicly, in the same manner. The Principal should destroy any coceived a copy of the original Power of Attorney or who may have dealt with the Agent acting on behalf of the Principal. It is a good idea to keep a record of anyone who was sent a copy of the revocatio the Principal, the Agent or the Notary should not be a witness. The Principal should keep a copy of the revocation in his/her files. Copies of the revocation should be sent to anyone who may have reough not always required, it is always a good idea to also have two witnesses sign the Revocation of Power of Attorney. The witnesses should be adults. Generally, anyone related by blood or marriage tified mail receipt, delivery receipt etc..). Any health care providers need to be given a copy of the Revocation as well and copies of the revocation should be kept in any relevant medical files. Alth show that it was the Grantor's intent to revoke the Power of Attorney. If possible, the Principal should keep a copy of any document showing that the Agent received the original revocation (i.e. certd. Notarization is also necessary to record the revocation. This revocation becomes effective immediately. The original or a copy of the revocation must be given to the Agent (i.e. Attorney-inFact) tohe Health Care Power of Attorney Revocation before a Notary even if it is not required. Notarization will also help to ensure that the revocation is effective and support its authenticity if challengeer of Attorney Revocation (3) Health Care Power of Attorney Revocation The Principal (i.e. the person granting the Health Care Power of Attorney Revocation; sometimes called the Grantor) should sign tInstructions & Checklist Health Care Power of Attorney Revocation This package includes (1) Checklist & Instructions for Health Care Power of Attorney Revocation (2) Information about Health Care Pow IndianaIndiana teen (18) years of age. Witness ________________________________________________ Date __________________ Witness ________________________________________________ Date __________________ ty and State of Residence ________________________________________________ The declarant has been personally known to me, and I believe (him/her) to be of sound mind. I am competent and at least eighical treatment and accept the consequences of the request. I understand the full import of this declaration. Signed: _______________________________________________________________________ City, Counons regarding the use of life prolonging procedures, it is my intention that this declaration be honored by my family and physician as the final expression of my legal right to request medical or surgministration of medication, and the performance of all other medical procedures necessary to extend my life, to provide comfort care, or to alleviate pain. In the absence of my ability to give directie injury, disease, or illness determined to be a terminal condition I request the use of life prolonging procedures that would extend my life. This includes appropriate nutrition and hydration, the ad____________________________________________________, being at least eighteen (18) years of age and of sound mind, willfully and voluntarily make known my desire that if at any time I have an incurabl_____________________________ Date __________________ 2 Life Prolonging Procedures DECLARATION Declaration made this _____________________ day of _____________________ (month, year). I, ____________for the declarant's medical care. I am competent and at least eighteen (18) years of age. Witness ________________________________________________ Date __________________ Witness ___________________ature above for or at the direction of the declarant. I am not a parent, spouse, or child of the declarant. I am not entitled to any part of the declarant's estate or directly financially responsible ___________________________________ City, County, and State of Residence The declarant has been personally known to me, and I believe (him/her) to be of sound mind. I did not sign the declarant's sign__________________________ I understand the full import of this declaration. Signed: _______________________________________________________________________ _______________________________________________________________________________________________________________ 1 ____________________________________________________________________________ __________________________________________________. Additional Instructions (optional): ____________________________________________________________________________ ____________________________________________________________________________ ________is my intention that this declaration 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 of the refusalntative appointed under IC 16-361-7 or my attorney in fact with health care powers under IC 30-5-5. In the absence of my ability to give directions regarding the use of life prolonging procedures, it ain life is futile or excessively burdensome to me. __________ I intentionally make no decision concerning artificially supplied nutrition and hydration, leaving the decision to my health care represeon and hydration, even if the effort to sustain life is futile or excessively burdensome to me. __________ I do not wish to receive artificially supplied nutrition and hydration, if the effort to sustn of artificially supplied nutrition and hydration. (Indicate your choice by initialing or making your mark before signing this declaration): __________ I wish to receive artificially supplied nutriti naturally with only the performance or provision of any medical procedure or medication necessary to provide me with comfort care or to alleviate pain, and, if I have so indicated below, the provisiot time; and (3) the use of life prolonging procedures would serve only to artificially prolong the dying process, I direct that such procedures be withheld or withdrawn, and that I be permitted to dieircumstances set forth below, and I declare: If at any time my attending physician certifies in writing that: (1) I have an incurable injury, disease, or illness; (2) my death will occur within a shor____________________________, being at least eighteen (18) years of age and of sound mind, willfully and voluntarily make known my desires that my dying shall not be artificially prolonged under the crs and Terms of Use found at findlegalforms.com Living Will DECLARATION Declaration made this _____________________ day of _____________________ (month, year). I, ____________________________________ith estate planning matters. Any possible tax consequences arising out of this document should be discussed with a tax professional. [_] The purchase and use of these forms is subject to the Disclaimeng point for you and should not be used or signed without consulting an attorney first to make sure it fits your particular situation. Advice from a local attorney is always recommended when dealing wl effect or completeness. [_]These forms are not intended and are not a substitute for legal and/or tax advice. Laws vary from time to time and from state to state. These forms should only be a startires withheld or withdrawn. [_] These forms are provided "as is" and no implied or express warranties have been made or are provided as to their suitability for any specific purpose or as to their legaunless the person had actual knowledge of the revocation. (d) The revocation of a life prolonging procedures will declaration is not evidence that the declarant desires to have life prolonging procedussion of intent to revoke. (b) A revocation is effective when communicated to the attending physician. (c) No civil or criminal liability is imposed upon a person for failure to act upon a revocation ng: (1) A signed, dated writing. (2) Physical cancellation or destruction of the declaration by the declarant or another in the declarant's presence and at the declarant's direction. (3) An oral expreor life prolonging procedures will declaration Sec. 12. (a) A living will declaration or a life prolonging procedures will declaration may be revoked at any time by the declarant by any of the followiirections. The invalidity of any additional, specific directions does not affect the validity of the declaration. As added by P.L.2-1993, SEC.19. IC 16-36-4-12 - Revocation of living will declaration - Forms of declaration; requisites Sec. 9. A declaration must be substantially in the form set forth in either section 10 or 11 of this chapter, but the declaration may include additional, specific d) A life prolonging procedures will declaration under section 11 of this chapter does require the physician to use life prolonging procedures as requested. As added by P.L.2-1993, SEC.19. IC 16-36-4-9thholding, or withdrawal of life prolonging procedures under this chapter; and (2) shall be given great weight by the physician in determining the intent of the patient who is mentally incompetent. (gnder section 10 of this chapter: (1) does not require the physician to use, withhold, or withdraw life prolonging procedures but is presumptive evidence of the patient's desires concerning the use, winding physician Information & Instructions ­ Page 3 who is notified shall make the declaration or a copy of the declaration a part of the declarant's medical records. (f) A living will declaration uing the person's pregnancy. (e) The life prolonging procedures will declarant or the living will declarant shall notify the declarant's attending physician of the existence of the declaration. An atted as a personal representative or as the attorney for the estate in the declarant's will. (d) The living will declaration of a person diagnosed as pregnant by the attending physician has no effect durly responsible for the declarant's medical care. For the purposes of subdivision (3), a person is not considered to be entitled to any part of the declarant's estate solely by virtue of being nominatent's estate whether the declarant dies testate or intestate, including whether the witness could take from the declarant's estate if the declarant's will is declared invalid. (4) Be directly financialditions: (1) Be the person who signed the declaration on behalf of and at the direction of the declarant. (2) Be a parent, spouse, or child of the declarant. (3) Be entitled to any part of the declarae presence of at least two (2) competent witnesses who are at least eighteen (18) years of age. (c) A witness to a living will declaration under subsection (b)(5) may not meet any of the following contary. (2) Be in writing. (3) Be signed by the person making the declaration or by another person in the declarant's presence and at the declarant's express direction. (4) Be dated. (5) Be signed in thnder section 11 of this chapter or a living will declaration under section 10 of this chapter. (b) A declaration under section 10 or 11 of this chapter must meet the following conditions: (1) Be volun procedures will declarations; living will declarations Sec. 8. (a) A person who is of sound mind and is at least eighteen (18) years of age may execute a life prolonging procedures will declaration uth care provider for the failure to provide medical treatment to a patient who has refused the treatment in accordance with this section. As added by P.L.2-1993, SEC.19. IC 16-36-4-8 - Life prolongingcedures. (b) No health care provider is required to provide medical treatment to a patient who has refused medical treatment under this section. (c) No civil or criminal liability is imposed on a healnt; immunity from liability for failure to treat patient after refusal of treatment Sec. 7. (a) A competent person may consent to or refuse consent for medical treatment, including life prolonging proave medical or surgical means or procedures calculated to prolong the competent adult's life provided, withheld, or withdrawn. As added by P.L.2-1993, SEC.19. IC 16-36-4-7 - Consent to medical treatmege 2 As added by P.L.2-1993, SEC.19. IC 16-36-4-6 - Policy Sec. 6. A competent adult has the right to control the decisions relating to the competent adult's medical care, including the decision to h: (1) there can be no recovery; and (2) death will occur from the terminal condition within a short period of time without the provision of life prolonging procedures. Information & Instructions ­ Pa6-4-5 - Terminal condition defined Sec. 5. As used in this chapter, "terminal condition" means a condition caused by injury, disease, or illness from which, to a reasonable degree of medical certaintyent defined Sec. 4. As used in this chapter, "qualified patient" means a patient who has been certified as a qualified patient under section 13 of this chapter. As added by P.L.2-1993, SEC.19. IC 16-3 used in this chapter, "living will declarant" means a person who has executed a living will declaration under section 10 of this chapter. As added by P.L.2-1993, SEC.19. IC 16-36-4-4 - Qualified pati means a person who has executed a life prolonging procedures will declaration under section 11 of this chapter. As added by P.L.2-1993, SEC.19. IC 16-36-4-3 - Living will declarant defined Sec. 3. Asdded by P.L.2-1993, SEC.19. Amended by P.L.99-1994, SEC.1. IC 16-36-4-2 - Life prolonging procedures will declarant defined Sec. 2. As used in this chapter, "life prolonging procedures will declarant" (2) Serves to prolong the dying process. (b) The term does not include the performance or provision of any medical procedure or medication necessary to provide comfort care or to alleviate pain. As a prolonging procedure" means any medical procedure, treatment, or intervention that does the following: (1) Uses mechanical or other artificial means to sustain, restore, or supplant a vital function.he Indiana Codes relating to Living Wills. IC 16-36-4 Chapter 4. Living Wills and Life Prolonging Procedures IC 16-36-4-1 - Life prolonging procedure defined Sec. 1. (a) As used in this chapter, "lifea Living Will; (3) Life Prolonging Declaration. This Indiana Living Will is based on Indiana Code Title 16-36 Chapter 4 Section 1 et. Seq. For your convenience, we have included useful excerpts from tInformation and Instructions Indiana Living Will & Life Prolonging Declaration This package contains (1) Information and Instruction for Indiana Living Will and Life Prolonging Declaration; (2) Indian IndianaIndiana _____ day of __________________, 20____. ______________________________________ (Notary Public) My Commission expires __________________ -2- mind, and under no constraint or undue influence. ___________________________________ (Principal) Subscribed and acknowledged before me by ______________________________________, the principal, this by declare to the undersigned witness that I sign it willingly, and I execute it as my free and voluntary act for the purposes herein expressed, and that I am eighteen years of age or older, of sound ugh intravenous, gastrostomy or nasogastric tubes.. I, ___________________________________, the principal, sign my name to this instrument this _______ day of ___________________ 20 _____, and do herenclude any medical care, treatment, service, or procedure to maintain, diagnose, treat, or provide for my physical or mental well-being, and also includes the providing of nutrition and hydration throlth care givers. To the extent appropriate, my health care representative may also discuss this decision with my family and others to the extent they are available. -1- I understand health care to i this decision with me. However, if I am unable to communicate, my health care representative may make such a decision for me, after consultation with my physician or physicians and other relevant heath care be withheld or withdrawn and may consent on my behalf that any or all health care be discontinued or not instituted, even if death may result. My health care representative must try to discusstisfied that certain health care is not or would not be beneficial or that such health care is or would be excessively burdensome, then my health care representative may express my will that such healin my best interest concerning withdrawal or withholding of health care. If at any time based on my previously expressed preferences and the diagnosis and prognosis my health care representative is sa______ (work telephone number) Appointment of my Attorney-in-Fact as my Health Care Representative In addition to the powers granted above, I authorize my health care representative to make decisions __________________________________________________ (name of successor attorney-in-fact) of _____________________________________________ (address) _________________ (home telephone number) ___________to request an autopsy; and (6) to make plans for the disposition of my body In the event the person I appoint above is unable, unwilling or unavailable to act as my attorneyin-fact, I hereby appoint: 2) to admit or release me from a hospital or health care facility; (3) to have access to my records, including medical records, concerning my condition; (4) to make anatomical gifts on my behalf; (5) th care decisions. I grant my attorney-in-fact the following powers in matters affecting my health care: (1) to employ or contract with servants, companions, or health care providers to care for me; (ess) _________________ (home telephone number) _________________ (work telephone number) as my attorney-in-fact to make health care decisions on my behalf whenever I am incapable of making my own heal mind, willfully and voluntarily appoint hereby appoint _________________________________________________ (name of attorney-in-fact) _____________________________________________________________ (addr.com -4- Power of Attorney for Health Care I, _________________________________________________________ (name) of ___________________________________________________________ (address) being of soundax consequences arising out of 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 findlegalformsent you should have an attorney review it to make sure it fits your particular situation. You should also consult an attorney whenever a document is negotiated with another party. Any -3- possible tvary from time to time and from state to state. These forms should only be a starting point for you and should not be used without consulting with an attorney first. Before using or signing this documr 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 advice. Laws rence the book and page or instrument number where the instrument creating the power of attorney is recorded. [_] These forms are provided "as is" and no implied or express warranties have been made oor other person has actual knowledge of the revocation. (c) If an executed power of attorney was recorded under IC 30-5-3-3, the revocation of the power of attorney must: (1) be recorded; and (2) refeten instrument of revocation that: (1) identifies the power of attorney revoked; and (2) is signed by the principal. (b) A revocation under subsection (a) is not effective unless the attorney in fact m of the contract notwithstanding. IC 30-5-10-1 Revocation of power; record Sec. 1. (a) Except as otherwise stated in the power of attorney, an executed power of attorney may be revoked only by a writicide for any purpose under a statute or rule of law and does not impair or invalidate an insurance, annuity, or other type of contract that is conditioned on the life or death of the principal, a teromply with the attorney in fact. (3) If the principal's death results from withholding or withdrawing health care in accordance with the terms of a power of attorney, the death is not a suicide or homds at the time of reference and the provider promptly transfers the principal to another health care provider, the provider is not subject to civil or criminal liability or discipline for failure to cthe principal results. (2) If the actions of a health care provider who fails to comply with a direction or decision of the attorney in fact are substantially in accord with reasonable medical standarr or other person is not subject to civil or criminal liability or discipline for unprofessional conduct for complying with a direction or decision by the attorney in fact, even if death or injury to al as a fully competent person. In addition, the following rules shall be applied to protect and validate the acts of the attorney in fact and provider or other person: -2- (1) A health care provide attorney is protected and released from liability to the same extent as the provider or other person would be protected or released if the provider or other person had dealt directly with the principrney in fact Sec. 10. A health care provider or other person who acts in good faith reliance on a direction or decision of an attorney in fact that is not clearly contrary to the terms of the power ofperson to whom the attorney in fact communicates a direction shall comply with the direction. IC 30-5-9-10 Health care providers; persons acting in good faith reliance on direction or decision of attorincipal's remains; the anatomical gift, autopsy, or remains disposition shall be considered the act of the principal or of the person who has priority under law to make the necessary decisions. Each ower of attorney authorizes the attorney in fact to: (1) make an anatomical gift on behalf of the principal; (2) authorize an autopsy of the principal's remains; or (3) direct the disposition of the pfamily and others to the extent they are available. (b) Nothing in this section may be construed to authorize euthanasia. IC 30-5-7-6 Anatomical gifts, autopsies, or remains disposition Sec. 6. If a pision for me, after consultation with my physician or physicians and other relevant health care givers. To the extent appropriate, my health care representative may also discuss this decision with my instituted, even if death may result. My health care representative must try to discuss this decision with me. However, if I am unable to communicate, my health care representative may make such a decively burdensome, then my health care representative may express my will that such health care be withheld or withdrawn and may consent on my behalf that any or all health care be discontinued or not pressed preferences and the diagnosis and prognosis my health care representative is satisfied that certain health care is not or would not be beneficial or that such health care is or would be excesssame form set forth below: I authorize my health care representative to make decisions in my best interest concerning withdrawal or withholding of health care. If at any time based on my previously exmands of the treatment and death may result. To empower the attorney in fact to act under this section, the following language must be included in an appointment under IC 16-36-1 in substantially the hapter, the attorney in fact may be empowered to ask in the name of the principal for health care to be withdrawn or withheld when it is not beneficial or -1- when any benefit is outweighed by the deion of the principal's body. IC 30-5-5-17 Consent to or refusal of health care Sec. 17. (a) If the attorney in fact has the authority to consent to or refuse health care under section 16(2) of this c4) Have access to records, including medical records, concerning the principal's condition. (5) Make anatomical gifts on the principal's behalf. (6) Request an autopsy. (7) Make plans for the disposit16-36-4 and IC 16-36-1 by properly executing and attaching to the power of attorney a declaration or appointment, or both. (3) Admit or release the principal from a hospital or health care facility. (anions, or health care providers to care for the principal. (2) If the attorney in fact is an individual, consent to or refuse health care for the principal who is an individual in accordance with IC h care. (b) Language conferring general authority with respect to health care powers means the principal authorizes the attorney in fact to do the following: (1) Employ or contract with servants, compo the individual's own health care or to the health care of another from consenting to health care administered in good faith under the religious tenets and practices of the individual requiring healtutes relating to the Indiana Power of Attorney for Health Care Form. IC 30-5-5-16 Health care powers; religious tenets Sec. 16. (a) This section does not prohibit an individual capable of consenting ty for Health Care Form. This Indiana Power of Attorney for Health Care is based on Title 30 Chapter 5 Section 30-5-5-16 of the Indiana Statutes. The following are useful excerpts from the Indiana StatInformation and Instructions Indiana Power of Attorney for Health Care This package contains (1) Information and Instruction for Indiana Power of Attorney for Health Care; (2) Indiana Power of Attorne IndianaIndiana _________________ Name: _______________________________________________ Address: ____________________________________________ City: _______________________________________________ State: ______________________________: _______________________________________________ State: _______________________________________________ SECOND WITNESS: Date: __________________ Signature: ___________________________________________ITNESS: Date: __________________ Signature: ___________________________________________ Name: _______________________________________________ Address: ____________________________________________ Cityion and in the presence of the Donor and each other. The individual signing the Donation of Gift was directed to do so by the Donor and signed the document in his/her presence as well as ours. FIRST Wnd by two witnesses, all of whom have signed at the direction and in the presence of the donor and of each other, and state that it has been so signed.] Witness Statement: We have signed at the direct____________________ WITNESS FORM [An anatomical gift may be made only by a document of gift signed by the donor. If the donor cannot sign, the document of gift must be signed by another individual a_ Print your name: ______________________________________ Address: ____________________________________________ City: _______________________________________________ State: ___________________________n, surgeon, technician, or enucleator to carry out the appropriate procedures. SIGNATURE: (Sign and date the form here:) Date: __________________ Sign your name: _____________________________________the appropriate procedures. In the absence of a designation or if the designee is not available, the donee or other person authorized to accept the anatomical gift may employ or authorize any physiciaof the following you do not want): (1) Transplant (2) Therapy (3) Research (4) Education (Optional) I designate ___________________________________ as my particular physician or surgeon to carry out __ ________________________________________________________________________ ________________________________________________________________________ My gift is for the following purposes (strike any x): Give any needed organs, tissues, or parts, OR Give the following organs, tissues, or parts only: ____________________________ ______________________________________________________________________ for all serious legal matters. Anatomical Gift by Living Donor Pursuant to Uniform Anatomical Gift Act Upon my death, I ____________________________________ (the "Donor"), hereby (mark applicable boand on any theory of liability, whether in contract, strict liability, or tort (including negligence or otherwise) arising in any way out of the use of these materials. An attorney should be consultedntal, special, exemplary, or consequential damages (including, but not limited to, procurement of substitute goods or services; loss of use, data, or profits; or business interruption) however caused risk. In no event will: i) FindLegalForms, Inc, its agents, partners, or affiliates, or ii) the providers, authors or publishers of the forms, be responsible or liable for any direct, indirect, incideovided "AS-IS." We do not give any express or implied warranties of merchantability, suitability or completeness for any of the materials for your particular needs. The materials are used at your own erials. FindLegalForms, Inc. does not provide legal advice. The purchase and use of these materials is subject to the "Disclaimers and Terms of Use" found at findlegalforms.com. These materials are pran anatomical gift. During a terminal illness or injury, the refusal may be an oral statement or other form of communication. Disclaimer No Attorney-Client relationship is created by use of these matocument of gift, (ii) a statement attached to or imprinted on a donor's motor vehicle operator's or chauffeur's license, or (iii) any other writing used to identify the individual as refusing to make the consent or concurrence of any person after the donor's death. An individual may refuse to make an anatomical gift of the individual's body or part by (i) a writing signed in the same manner as a ddelivery of a signed statement to a specified donee to whom a document of gift had been delivered. An anatomical gift that is not revoked by the donor before death is irrevocable and does not require ) a signed statement; (2) an oral statement made in the presence of two individuals; (3) any form of communication during a terminal illness or injury addressed to a physician or surgeon; or (4) the f, after death, the will is declared invalid for testamentary purposes, the validity of the anatomical gift is unaffected. A donor may amend or revoke an anatomical gift, not made by will, only by: (1ze any physician, surgeon, technician, or enucleator to carry out the appropriate procedures. An anatomical gift by will takes effect upon death of the testator, whether or not the will is probated. In to carry out the appropriate procedures. In the absence of a designation or if the designee is not available, the donee or other person authorized to accept the anatomical gift may employ or authories, all of whom have signed at the direction and in the presence of the donor and of each other, and state that it has been so signed. A document of gift may designate a particular physician or surgeo least 18 years of age. An anatomical gift may be made by a document of gift signed by the donor. If the donor cannot sign, the document of gift must be signed by another individual and by two witness Instructions for preparing your Anatomical Gift Anatomical Gift Form To make an anatomical gift, limit an anatomical gift or refuse to make an anatomical gift, an individual must in most cases be atvides tools and guidelines to assist you in creating your Anatomical Gift and is designed to fulfill the obligations of the Uniform Anatomical Gift Act. Included in this kit are the following: Generalour wishes regarding the disposition of your body will be ignored. By preparing a written Anatomical Gift, you can rest assured that your desire to donate your organs will be carried out. This kit proFindLegalForms.com Information Donation Pursuant to the Uniform Anatomical Gift Act (by Living Donor) No one likes considering their own death, but by avoiding the subject, it is likely that many of y IndianaIndiana ________ n whose name is subscribed to this instrument appears to be of sound mind and under no duress, fraud, or undue influence. _____________________________ Notary Public My commission expires ____________ersonally and, under oath, stated that he or she is the person described in the above document and he or she signed the above document in my presence. I declare under penalty of perjury that the perso_________________________________ Notary Acknowledgment (Optional) State of ____________________ County of ____________________ On ____________________, ______________________________ came before me pignature of Donor ______________________________ Printed Name of Donor Address: ____________________________________________ City: _______________________________________________ State: ______________y written revocation of my Anatomical Gift. This statement will be delivered to all specified donees, if any, to whom a document of gift had been previously delivered. ______________________________ Sication during a terminal illness or injury addressed to a physician or surgeon; or (4) the delivery of a signed statement to a specified donee to whom a document of gift had been delivered. This is m of this state, a donor may amend or revoke an anatomical gift, not made by will, only by: (1) a signed statement; (2) an oral statement made in the presence of two individuals; (3) any form of commun__________________, I, ______________________________, the donor, fully and completely revoke the Anatomical Gift dated __________________________. Pursuant to Uniform Anatomical Gift Act and the lawsft Act, you should check the laws of your state to determine whether there are any other requirements you must meet to revoke your Anatomical Gift. Revocation of Anatomical Gift On this date ________estroy the original and all copies of your Anatomical Gift or cross out each page of the forms and mark "REVOKED" across them in bold print. Although most states have adopted the Uniform Anatomical Giorm notarized. You should also make certain that a copy of any revocation is provided to anyone who has a copy of your original Anatomical Gift, including any designated donees. You should also then dted. When you have completed the form and printed it, sign the form and make certain that you store the original where you had stored the original of your Anatomical Gift. You may choose to have the f. An anatomical gift that is not revoked by the donor before death is irrevocable and does not require the consent or concurrence of any person after the donor's death. Complete the information requesm of communication during a terminal illness or injury addressed to a physician or surgeon; or (4) the delivery of a signed statement to a specified donee to whom a document of gift had been deliveredn of Anatomical Gift form. A donor may amend or revoke an anatomical gift, not made by will, only by: (1) a signed statement; (2) an oral statement made in the presence of two individuals; (3) any foray out of the use of these materials. An attorney should be consulted for all serious legal matters. Revoking Your Anatomical Gift Instructions Following these instructions, you will find a Revocatios of use, data, or profits; or business interruption) however caused and on any theory of liability, whether in contract, strict liability, or tort (including negligence or otherwise) arising in any w the forms, be responsible or liable for any direct, indirect, incidental, special, exemplary, or consequential damages (including, but not limited to, procurement of substitute goods or services; loserials for your particular needs. The materials are used at your own risk. In no event will: i) FindLegalForms, Inc, its agents, partners, or affiliates, or ii) the providers, authors or publishers ofand Terms of Use" found at findlegalforms.com. These materials are provided "AS-IS." We do not give any express or implied warranties of merchantability, suitability or completeness for any of the matlaimer No Attorney-Client relationship is created by use of these materials. FindLegalForms, Inc. does not provide legal advice. The purchase and use of these materials is subject to the "Disclaimers esigned to fulfill the requirements of the Uniform Anatomical Gift Act. Included in this kit is the following: General Instructions for Revoking Your Anatomical Gift Revocation of Anatomical Gift Discnt to revoke the document. Until your death, it is your right to revoke your Anatomical Gift at any time. This kit provides tools and guidelines to assist you in revoking your Anatomical Gift and is dFindLegalForms.com Information Revoking an Anatomical Gift (Organ Donation Revocation) You prepared a written Anatomical Gift, but now because of a change of circumstances or a change of heart, you wa IndianaIndiana _____________ Name of Survivor: _______________________________ Address: ____________________________________________ City: _______________________________________________ State: __________________________________urposes (strike any of the following you do not want): (1) Transplant (2) Therapy (3) Research (4) Education Date: __________________ Signature of Survivor: __________________________________ Printed_______________ ________________________________________________________________________ ________________________________________________________________________ III. The gift is for the following pthe applicable box): Give any needed organs, tissues, or parts, OR Give the following organs, tissues, or parts only: _______________________ _________________________________________________________ity and state). I. I survive the decedent as (mark the appropriate box): spouse; adult son or daughter; parent; adult brother or sister; grandparent; or guardian of the decedent. II. I hereby (mark this anatomical gift from the body of __________________________________(name of decedent) who died on _____________, 20___ at_______________________________ in ____________________________________ (corney should be consulted for all serious legal matters. Anatomical Gift by Next of Kin or Guardian of the Person Pursuant to the Uniform Anatomical Gift Act and the law of this state, I hereby make rruption) however caused and on any theory of liability, whether in contract, strict liability, or tort (including negligence or otherwise) arising in any way out of the use of these materials. An att direct, indirect, incidental, special, exemplary, or consequential damages (including, but not limited to, procurement of substitute goods or services; loss of use, data, or profits; or business inteals are used at your own risk. In no event will: i) FindLegalForms, Inc, its agents, partners, or affiliates, or ii) the providers, authors or publishers of the forms, be responsible or liable for anym. These materials are provided "AS-IS." We do not give any express or implied warranties of merchantability, suitability or completeness for any of the materials for your particular needs. The materieated by use of these materials. FindLegalForms, Inc. does not provide legal advice. The purchase and use of these materials is subject to the "Disclaimers and Terms of Use" found at findlegalforms.con for the removal of a part from the body of the decedent, the physician, surgeon, technician, or enucleator removing the part knows of the revocation. Disclaimer No Attorney-Client relationship is cr a member of the person's class or a prior class. An anatomical gift by a person authorized under subdivision may be revoked by any member of the same or a prior class if, before procedures have beguoposing to make an anatomical gift knows of a refusal or contrary indications by the decedent. (3) The person proposing to make an anatomical gift knows of an objection to making an anatomical gift byAn anatomical gift may not be made by a person listed above if any of the following occur: (1) A person in a prior class is available at the time of death to make an anatomical gift. (2) The person pre decedent; (3) either parent of the decedent; (4) an adult brother or sister of the decedent; (5) a grandparent of the decedent; and (6) a guardian of the person of the decedent at the time of death ker for an authorized purpose, unless the decedent, at the time of death, has made an unrevoked refusal to make that anatomical gift: (1) the spouse of the decedent; (2) an adult son or daughter of th Gift Form An anatomical gift may be made any member of the following classes of persons, in the order of priority listed, may make an anatomical gift of all or part of the decedent's body or a pacemas made on behalf of the decedent by the next of kin or guardian. Included in this kit are the following: General Instructions for preparing your Anatomical Gift (by next of kin or guardian) Anatomicalt. As the next of kin or guardian, you can prepare and execute an Anatomical Gift on behalf of the decedent. This kit is designed to fulfill the obligations of the Uniform Anatomical Gift Act for giftFindLegalForms.com Information Donation Pursuant to the Uniform Anatomical Gift Act (by Next of Kin or Guardian) A loved one has died and you believe that he/she would desire to make an Anatomical Gif Indiana