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Iowa ame: ___________________________________ Address: ______________________________________ Phone: _______________________________________ _______________________________ Address: ______________________________________ Phone: _______________________________________ _____________________________________________ (Witness Signature) Print N__________________________________________________ __________________________________________ (Declarant's Signature) _____________________________________________ (Witness Signature) Print Name: _________________________ Address: __________________________________________________________________ ______________________________________ Zip Code: ___________________________ Phone: _______________________________________________________________________________________ ____________________________________________________________________________ Name: _______________________________________________ong the dying process and are not necessary to my comfort or freedom from pain. Additional Instructions (optional): ____________________________________________________________________________ _______nistration of life-sustaining procedures. If I am unable to participate in my health care decisions, I direct my attending physician to withhold or withdraw life-sustaining procedures that merely prolhort period of time or a state of permanent unconsciousness from which, to a reasonable degree of medical certainty, there can be no recovery, it is my desire that my life not be prolonged by the admis is subject to the Disclaimers and Terms of Use found at findlegalforms.com Living Will If I should have an incurable or irreversible condition that will result either in death within a relatively sys recommended when dealing 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 formforms should only be a starting point for you and should not be used or signed without consulting an attorney first to make sure it fits your particular situation. Advice from a local attorney is alwac 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 vary from time to time and from state to state. These d not, be in the following form: (Form included below). [_] These forms are provided "as is" and no implied or express warranties have been made or are provided as to their suitability for any specifion & Instructions ­ Page 2 federal department of veterans affairs advance directive requirements shall be deemed valid and enforceable. 5. A declaration executed pursuant to this chapter may, but neent the declaration or similar document is consistent with the laws of this state. A declaration or similar document executed by a veteran of the armed forces which is in compliance with the Informati4. A declaration or similar document executed in another state or jurisdiction in compliance with the law of that state or jurisdiction shall be deemed valid and enforceable in this state, to the exteovider with the declaration. An attending physician or health care provider may presume, in the absence of actual notice to the contrary, that the declaration complies with this chapter and is valid. han eighteen years of age. b. Is acknowledged before a notarial officer within this state. 3. It is the responsibility of the Declarant to provide the Declarant's attending physician or health care pr(1) A health care provider attending the Declarant on the date of execution. (2) An employee of a health care provider attending the Declarant on the date of execution. (3) An individual who is less tl be an individual who is not a relative of the Declarant by blood, marriage, or adoption within the third degree of consanguinity. The following individuals shall not be witnesses for a declaration: her and the Declarant, witnessed the signing of the declaration by the Declarant or by another person acting on behalf of the Declarant at the Declarant's direction. At least one of the witnesses shalf the Declarant, must contain the date of its execution, and must be witnessed or acknowledged by one of the following methods: a. Is signed by at least two individuals who, in the presence of each otined to be terminal and the Declarant is not able to make treatment decisions. 2. The declaration must be signed by the Declarant or another person acting on behalf of the Declarant at the direction olt may execute a declaration at any time directing that life-sustaining procedures be withheld or withdrawn. The declaration shall be given operative effect only if the Declarant's condition is determwa Statutes For your convenience, we have included useful excerpts from the Iowa Statutes relating to Living Wills. 144A.3 Declaration relating to use of life-sustaining procedures. 1. A competent aduInformation and Instructions Iowa Living Will This package contains (1) Information and Instruction for Iowa Living Will; (2) Iowa Living Will. This Iowa Living Will is based on Chapter 144A of the Io Iowa