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Indiana _____________ Name typed, printed, or stamped -5- ly known to me or who has produced ________________________________ as identification. _________________________________ Signature of person taking acknowledgment (Notary Public) ____________________unty of ________________________ ) The foregoing instrument was acknowledged before me this _____ day of ____________________, ______ by __________________________ (name of Principal), who is personalignature: ___________________________________ Name: ___________________________________ City: __________________________________ State: ___________________________________ State of INDIANA ) ) ss CoPrincipal Witness Signature: ___________________________________ Name: ___________________________________ City: __________________________________ State: ___________________________________ Witness Shis Power of Attorney at any time by providing written notice to my Agent. Signed on ________________ (date), at _______________________ (city), Indiana. ________________________________ Signature of od 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 telying 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 gomnify 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 indeghts 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 who rent 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 rifect 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 Agy 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 ef 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 an 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 beesult 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 or 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 a rt 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 evaluateution 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 subsequenaimed 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 exectributed 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 discl 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 disgent'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 trusteeexercise 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 my A (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, (b) nt 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 document,e 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 amoutate 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 thmy 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 any s 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 of , 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 informationncluding 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 federalor 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, iwise 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 and/cess 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 otherical 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 achecks 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 politns; 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 cut not limited to, checking accounts, savings accounts, certificates of deposit, investment accounts, brokerage accounts, retirement plan accounts, and other similar accounts with financial institutiots), 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, brmation, 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 benefiny annuity, pension, retirement benefits, retirement plans, insurance benefits and government program including, but not limited to, Social Security and Medicare; to prepare applications, provide info 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 aue 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 thead 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 become dgible 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 homestehange, 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, tanby, 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, excon, 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, owned ed 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 actibe. 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 assertdences 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 may cial 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, evids, options, trust deeds, security agreements, leases, mortgages, notes, insurance policies, receipts, title documents, checks, drafts, letters of credit, stock certificates, proxies, warrants, commer 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, deeand 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 agreementhall 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 in, erty, 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, shority 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, propt") 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 aut ____________________________________ ("Principal") maintaining an address at _______________________________________________ do hereby make and appoint ________________________________________ ("Agen__________________________ Address: _______________________________________ Phone:______________________ INDIANA DURABLE POWER OF ATTORNEY Effective Immediately KNOW ALL PERSONS BY THESE PRESENTS: I,ater 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: _______________tions 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 lhe 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 queseping. 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 swee 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 instructPower 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 notecially 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, espould 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 shThis 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 used petent 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. s 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" com 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 int 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 pointy-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 Agerincipal 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 P 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 willtion 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 eveInstructions & Checklist Indiana Durable Power of Attorney Effective Immediately [_] This package contains (1) Instructions & Checklist for Durable Power of Attorney Effective Immediately; (2) Informa IndianaIndiana 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 _________________________________ Signature of person taking acknowledgment (Notary Public) _________________________________ Name typed, printed, or stamped -5- this _____ day of ____________________, ______ by __________________________ (name of Principal), who is personally known to me or who has produced ________________________________ as identification. City: __________________________________ State: ___________________________________ State of INDIANA ) ) ss County of ________________________ ) The foregoing instrument was acknowledged before me__________________ City: __________________________________ State: ___________________________________ Witness Signature: ___________________________________ Name: ______________________________________________ (date), at _______________________ (city), Indiana. ________________________________ Signature of Principal Witness Signature: ___________________________________ Name: _________________od 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 _____, 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 in goe 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 terminationot 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 reliancAgent; 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 is nimited 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 my easons 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 are ler 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 the rs, 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 undl 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, rightll 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 shalrces 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 shaor 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 resoucome 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 disability ed, 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 shall be, 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 entitlfer 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 document) 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 transreditors 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 any ofically 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 the ceral 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 specife 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 fedse, 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 to thts 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 otherwis; 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 giffile 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 documentassistance 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/or r 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 business d 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 othery 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, an 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. Treasuals, 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 any 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 withdrawr close bank accounts, including, but not limited to, checking accounts, savings accounts, certificates of deposit, investment accounts, brokerage accounts, retirement plan accounts, and other similarmilitary 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 and/o 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, medical, cover 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; to 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, includingght 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 and rel 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 riell, 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 personaow 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, rent, sers, 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 disputed, nle 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 papf 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 sett 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 writing oficates, 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 otherracts, covenants, conveyances, deeds, options, trust deeds, security agreements, leases, mortgages, notes, insurance policies, receipts, title documents, checks, drafts, letters of credit, stock certi 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, contted 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, endorseent'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 limitransaction, 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 my Aggent 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, item, ___________________________ ("Agent") maintaining an address at: _____________________________________________________ my true and lawful attorney-in-fact for me and in my name, and in my behalf. My A ALL PERSONS BY THESE PRESENTS: I, ____________________________________ ("Principal") maintaining an address at _______________________________________________ do hereby make and appoint _____________agent. -3- Document Prepared by: Name: _________________________________________ Address: _______________________________________ Phone:______________________ INDIANA GENERAL POWER OF ATTORNEY KNOWfor 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 an ment, 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 decisions 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 docued 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 handle 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 granttor 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 isbe 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 Granhe 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 Attorney 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 challenge tAgent, 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 should pointed 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 the led 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 aphe "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 disabforms.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 (called tney 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 findlegalncipal'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 attorr 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 Prihe 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 Grantoana, 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. Te 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 Indirded 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 b 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 recoeral 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 Indiana General Power of Attorney [_] This package contains (1) Instructions & Checklist for General Power of Attorney; (2) Information for General Power of Attorney; (3) Gen IndianaIndiana ____________ as identification. _________________________________ Signature of person taking acknowledgment (Notary Public) _________________________________ Name typed, printed, or stamped -4- ment was acknowledged before me this _____ day of ____________________, ______ by __________________________ (name of Principal), who is personally known to me or who has produced ____________________ person taking acknowledgment (Notary Public) _________________________________ Name typed, printed, or stamped -3- State of INDIANA ) ) ss County of ________________________ ) The foregoing instru by __________________________ (name of Principal), who is personally known to me or who has produced ________________________________ as identification. _________________________________ Signature ofate: ___________________________________ State of INDIANA ) ) ss County of ________________________ ) The foregoing instrument was acknowledged before me this _____ day of ____________________, ______________________ State: ___________________________________ Witness Signature: ___________________________________ Name: ___________________________________ City: __________________________________ St_____ Signature of Father ________________________________ Signature of Mother Witness Signature: ___________________________________ Name: ___________________________________ City: __________________y before the expiration date at any time by providing written notice to the Attorney-in-Fact. Signed on ________________ (date), at _______________________ (city), Indiana. ___________________________erminated 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 Attornectual 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 is td 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 has af 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 affectehe 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 ond 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 and ten. 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 document aor 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/childrvers, 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 withhold 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, waier 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 health ers. 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 othal 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 mattchools 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 educationy 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 programs, s 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, X-rawhose 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, dentaluding, 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 person 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, incl_____________________________ born on __________ Name: _________________________________ born on __________ Name: _________________________________ born on __________ The above named Attorney-in-Fact ld/children: Name: _________________________________ born on __________ Name: _________________________________ born on __________ Name: _________________________________ born on __________ Name: ____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 chi to as "Parents" or "Principals", maintaining an address at: ________________________________________ hereby make and appoint ________________________________________ ("Attorney-in-Fact") maintaining OR THE CARE OF CHILDREN KNOW ALL PERSONS BY THESE PRESENTS: We ______________________________________________________ ("Father") and ______________________________________ ("Mother"), jointly referredonsibilities of an agent. -3- Document Prepared by: Name: _________________________________________ Address: _______________________________________ Phone:______________________ POWER OF ATTORNEY Fmpetent 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 resp/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, obtain coing 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 childered 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 signs 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 offalidity 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 intended adate. 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 the vney-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 expiration d 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 Attorgenerally 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 grantebetter 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 also 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 to 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 granted by 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 maked 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 theary 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 calle 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 necessg. [_] 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. [_]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 sweepin or Notary should not be a witness. [_] In Indiana, 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 be equired, 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-Factuld 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 always re 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 sho) 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 thInstructions & Checklist Indiana 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 (3 IndianaIndiana ___ nd at least eighteen (18) years of age. Witness ________________________________________________ Date __________________ Witness ________________________________________________ Date ___________________ 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 am competent amedical or surgical treatment and accept the consequences of the request. I understand the full import of this declaration. Signed: ___________________________________________________________________to give directions 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 dration, the administration 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 ave an incurable 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 hyI, ________________________________________________________________, 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 h____________________________________________ Date __________________ 2 Life Prolonging Procedures DECLARATION Declaration made this _____________________ day of _____________________ (month, year). ly responsible for the declarant's medical care. I am competent and at least eighteen (18) years of age. Witness ________________________________________________ Date __________________ Witness ____eclarant's signature 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 financial_________________________________________________ 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 d_____________________________________ I understand the full import of this declaration. Signed: _______________________________________________________________________ _______________________________ ____________________________________________________________________________ 1 ____________________________________________________________________________ _______________________________________he refusal. Additional Instructions (optional): ____________________________________________________________________________ __________________________________________________________________________dures, it 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 te representative 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 proce to sustain 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 carnutrition 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 effortovision 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 to die 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 pra short 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 the circumstances 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 __________________________________, 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 underclaimers and Terms of Use found at findlegalforms.com Living Will DECLARATION Declaration made this _____________________ day of _____________________ (month, year). I, ______________________________ling with 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 Disstarting 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 dear legal 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 rocedures 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 theiation unless 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 p expression 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 revocollowing: (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 oralation or 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 fific directions. 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 declar36-4-9 - 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, specnt. (g) 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-se, withholding, 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 incompetetion under 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 uphysician Living Will 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 declarae 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 attending 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 during thponsible 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 nominated as astate 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 financially ress: (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 declarant's eence 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 condition(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 the presection 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 voluntary. dures 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 under se 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 prolonging proce. (b) No health care provider is required to provide medical treatme nt to a patient who has refused medical treatment under this section. (c) No civil or criminal liability is imposed on a health carunity 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 proceduresical 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 treatment; imms 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 have medno recovery; and (2) death will occur from the terminal condition within a short period of time without the provision of life prolonging procedures. Living Will Information & Instructions ­ Page 2 Andition 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 certainty: (1) there can be 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 16-36-4-5 - Terminal coer, "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 patient defined Sec. 4. 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. As used in this chapt 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" means a person whoong 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 added by P.L.2-1993,re" 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. (2) Serves to prollating 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, "life prolonging proceduLife 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 the Indiana Codes retructions Indiana Living Will & Life Prolonging Declaration This package contains (1) Information and Instruction for Indiana Living Will and Life Prolonging Declaration; (2) Indiana Living Will; (3) ______________, the principal, this _____ day of __________________, 20____. ______________________________________ (Notary Public) My Commission expires __________________ -2- Information and Insen years of age or older, of sound mind, and under no constraint or undue influence. ___________________________________ (Principal) Subscribed and acknowledged before me by _____________________________________ 20 _____, and do hereby 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 eighteng of nutrition and hydration through intravenous, gastrostomy or nasogastric tubes.. I, ___________________________________, the principal, sign my name to this instrument this _______ day of ______-1- I understand health care to include any medical care, treatment, service, or procedure to maintain, diagnose, treat, or provide for my physical or mental well-being, and also includes the providi physicians and other relevant health 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. representative must try to discuss 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 ormay 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 instituted, even if death may result. My health care y 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 excessively burdensome, then my health care representative representative to make decisions in 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 mome telephone number) _________________ (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 careneyin- fact, I hereby appoint: __________________________________________________ (name of successor attorney- in- fact) of _____________________________________________ (address) _________________ (hmical gifts on my behalf; (5) 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 attorre providers to care for me; (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 anatoapable of making my own health 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 ca____________________ (address) _________________ (home telephone number) _________________ (work telephone number) as my attorney- in- fact to make health care decisions on my behalf whenever I am inc (address) being of sound mind, willfully and voluntarily appoint hereby appoint _________________________________________________ (name of attorney- in-fact) _________________________________________e found at findlegalforms.com -4- Power of Attorney for Health Care I, _________________________________________________________ (name) of ___________________________________________________________rty. Any -3- 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 Disclaimers and Terms of Using or signing this document 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 pa 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 without consulting with an attorney first. Before usrranties have been made or are provided as to their suitability for any specific purpose or as to their legal effect or completeness. [_]These forms are not intended and are not a substitute for legale recorded; and (2) reference 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 wass the attorney in fact or 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 revoked only by a written 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 unleof the principal, a term 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 bis not a suicide or homicide 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 ipline for failure to comply 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 sonable medical standards 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 disc if death or injury to the 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 rea) A health care provider 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, evenrectly with the principal 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- (1e terms of the power of 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 diion or decision of attorney 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 thssary decisions. Each person 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 directe disposition of the principal'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 neceosition Sec. 6. If a power 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 thhis decision with my family 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 dispe may make such a decision 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 t discontinued or not 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 representativis or would be excessively 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 bed on my previously expressed 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 in substantially the same 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 base outweighed by the demands 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 ction 16(2) of this chapter, 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 isans fo r the disposition 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 selth care facility. (4) 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 pl accordance with IC 16-36-4 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 hea with servants, companions, 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 indual requiring health 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 contractable of consenting to 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 indiviom the Indiana Statutes 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 capna Power of Attorney 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 frindlegalforms.com Information 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) Indiay possible tax conseque nces 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 f 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 with estate planning matters. Anese forms are not intended and are not a substitute for legal and/or tax advice. Laws vary from time to time and from state to state. These forms should only be a starting point for you and should notThese forms are provided "as is" and no implied or express warranties have been made or are provided as to their suitability for any specific purpose or as to their legal effect or completeness. [_]Thlth Care Directive. This package also includes the Indiana Life Prolonging Procedures Declaration. The first form is the Power of Attorney for Health Care and the second form is the Living Will. [_] Indiana Advance Health Care Directive This package contains both a Indiana Power of Attorney for Health Care and a Indiana Living Will. Together these forms are also sometimes known as an Advance Hea Indiana