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Kansas me of person) ______________________________________ (Signature of notary public) (Seal, if any) My appointment expires:__________________________ 2 _________ (OR) STATE OF KANSAS ) )SS. COUNTY OF ________________________ ) This instrument was acknowledged before me on ____________________________ (date) by _________________________________ (naddress: ______________________________________ _____________________________________________ (Witness Signature) Print Name: ___________________________________ Address: _____________________________ codicil thereto, or directly financially responsible for Declarant's medical care. _____________________________________________ (Witness Signature) Print Name: ___________________________________ Aeclarant. I am not related to the Declarant by blood or marriage, entitled to any portion of the estate of the Declarant according to the laws of intestate succession or under any will of Declarant or before a notary public. The Declarant has been personally known to me and I believe the Declarant to be of sound mind. I did not sign the Declarant's signature above for or at the direction of the Daccording to the laws of intestate succession of this state or under any will of the Declarant or codicil thereto, or directly financially responsible for Declarant's medical care; OR (2) acknowledgedho signed the declaration on behalf of and at the direction of the person making the declaration, related to the Declarant by blood or marriage, entitled to any portion of the estate of the Declarant ____________________________________ (Declarant's Signature) 1 This document must be signed in the presence of (1) two or more witnesses at least 18 years of age neither of whom shall be the person w_______________________________________ Address: __________________________________________________________________ ______________________________________ Zip Code: ___________________________ _________________________________________________ I understand the full import of this declaration and I am emotionally and mentally competent to make this declaration. Name: _________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ _________________________________ legal right to refuse medical or surgical treatment and accept the consequences from such refusal. Additional Instructions (optional): ________________________________________________________________y ability to give directions regarding the use of such life-sustaining procedures, it is my intention that this declaration shall be honored by my family and physician(s) as the final expression of myn, and that I be permitted to die naturally with only the administration of medication or the performance of any medical procedure deemed necessary to provide me with comfort care. In the absence of maining procedures are utilized and where the application of life-sustaining procedures would serve only to artificially prolong the dying process, I direct that such procedures be withheld or withdraw terminal condition by two physicians who have personally examined me, one of whom shall be my attending physician, and the physicians have determined that my death will occur whether or not life-sustre that my dying shall not be artificially prolonged under the circumstances set forth below, do hereby declare: If at any time I should have an incurable injury, disease, or illness certified to be aWill DECLARATION Declaration made this ___________ day of ______ (month, year). I, __________________________________________________, being of sound mind, willfully and voluntarily make known my desies 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 findlegalforms.com Living consulting an attorney first to make sure it fits yo ur particular situation. Advice from a local attorney is always recommended when dealing with estate planning matters. Any possible tax consequenc 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 not be used or signed withoutas 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. [_]These forms are not intended not affect other directions of the declaration which can be given effect without the invalid direction, and to this end the directions in the declaration are severable. [_] These forms are provided " form, but in addition may include other specific directions. Should any of the other specific directions be held to be invalid, such Living Will Information & Instructions ­ Page 2 invalidity shall attending physician who is so notified shall make the declaration, or a copy of the declaration, a part of the Declarant's medical records. (c) The declaration shall be substantially in the following course of the qualified patient's pregnancy. (b) It shall be the responsibility of Declarant to provide for notification to the Declarant's attending physician of the existence of the declaration. Annsible for Declarant's medical care; or (B) acknowledged before a notary public. The declaration of a qualified patient diagnosed as pregnant by the attending physician shall have no effect during the entitled to any portion of the estate of the Declarant according to the laws of intestate succession of this state or under any will of the Declarant or codicil thereto, or directly financially respost 18 years of age neither of whom shall be the person who signed the declaration on behalf of and at the direction of the person making the declaration, related to the Declarant by blood or marriage,erson making the declaration, or by another person in the Declarant's presence and by the Declarant's expressed direction; (3) dated; and (4) (A) signed in the presence of two or more witnesses at leacute a declaration directing the withholding or withdrawal of lifesustaining procedures in a terminal condition. The declaration made pursuant to this act shall be: (1) In writing; (2) signed by the p5-28,103. Same; declaration authorizing; effect during pregnancy of qualified patient; duty to notify attending physician; form of declaration; severability of directions. (a) Any adult person may exetatutes Chapter 65 Article 28 et. Seq. For your convenience, we have included useful excerpts from the Kansas Statutes relating to Living Wills. Chapter 65.--PUBLIC HEALTH Article 28.--HEALING ARTS 6 -3- Information and Instructions Kansas Living Will This package contains (1) Information and Instruction for Kansas Living Will; (2) Kansas Living Will. This Kansas Living Will is based on Kansas S__ (date) by _________________________________ (name of person) ______________________________________ (Signature of notary public) (Seal, if any) My appointment expires:__________________________ ___________ Address: ______________________________________ (OR) STATE OF KANSAS ) )SS. COUNTY OF ________________________ ) This instrument was acknowledged before me on __________________________ Print Name: ___________________________________ Address: ______________________________________ _____________________________________________ (Witness Signature) Print Name: ________________________ortion of principal's estate and not financially responsible for principal's health care; OR (2) acknowledged before a notary public. _____________________________________________ (Witness Signature)__________________ -2- This document must be: (1) Witnessed by two individuals of lawful age who are not the agent, not related to the principal by blood, marriage or adoption, not entitled to any pein or set out another manner of revocation, if desired. EXECUTION Executed this ____________, at _________________________, Kansas. Signature of Principal: _________________________________________sly made is hereby revoked. This durable power of attorney for health care decisions shall be revoked by an instrument in writing executed, witnessed or acknowledged in the same manner as required herall not be affected by my subsequent disability or incapacity or upon the occurrence of my disability or incapacity). REVOCATION Any durable power of attorney for health care decisions I have previou_____________ ______________________________________________________________________________ EFFECTIVE TIME This power of attorney for health care decisions shall become effective (immediately and shall be subject to the additional following limitations: ______________________________________________________________________________ _________________________________________________________________________________________________________________________ ______________________________________________________________________________ (3) This durable power of attorney for health care decisions shath act. -1- (2) The agent shall be prohibited from authorizing consent for the following items: ______________________________________________________________________________ ______________________ writing in this durable power of attorney for health care decisions, and shall not include the power to revoke or invalidate any previously existing declaration made in accordance with the natural de__________________ ______________________________________________________________________________ LIMITATIONS OF AUTHORITY (1) The powers of the agent herein shall be limited to the extent set out in____________________________________________________________ ______________________________________________________________________________ ____________________________________________________________health care decisions shall (Here may be inserted any special instructions or statement of the principal's desires to be followed by the agent in exercising the authority granted).: __________________medical and hospital records and to execute any releases of other documents that may be required in order to obtain such information. In exercising the grant of authority set forth above my agent for ecessary for my physical, mental and emotional well being; and (3) request, receive and review any information, verbal or written, regarding my personal affairs or physical or mental health including logists, dentists, nurses, the rapists or any other person who is licensed, certified or otherwise authorized or permitted by the laws of this state to administer health care as the agent shall deem nospital, psychiatric hospital or psychiatric treatment facility, hospice, nursing home or similar institution; to employ or discharge health care personnel to include physicians, psychiatrists, psychor procedure to maintain, diagnose or treat a physical or mental condition, and to make decisions about organ donation, autopsy and disposition of the body; (2) make all necessary arrangements at any helephone Number) to be my agent for health care decisions and pursuant to the language stated below, on my behalf to: (1) Consent, refuse consent, or withdraw consent to any care, treatment, service o: _____________________________________________________________ (Name ) maintaining an address at: _______________________________________________________ (Address) ________________________________ (Tlegalforms.com -3- Durable Power of Attorney for Health Care Decisions GENERAL STATEMENT OF AUTHORITY GRANTED I, _____________________________________________________________ , designate and appointpossible 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 Use found at findgning 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 party. Any ax 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 using or sihave 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 legal and/or tecisions without knowledge of its invalidity shall be immune from liability that may be incurred or imposed from such action. [_] These forms are provided "as is" and no implied or express warranties te acts of the agent in arranging for organ donation, autopsy or disposition of body. -2- (g) Any person who in good faith acts pursuant to the terms of a durable power of attorney for health care dprincipal or codicil thereto, or directly financially responsible for the principal's health care; or (2) acknowledged before a notary public. (f) Death of the principal shall not prohibit or invalidat, related to the principal by blood, marriage or adoption, entitled to any portion of the estate of the principal according to the laws of intestate succession of this state or under any will of the alth care services. (e) A durable power of attorney for health care decisions shall be: (1) Dated and signed in the presence of two witnesses at least 18 years of age neither of whom shall be the agenligious life and who conduct or assist in the conduct of religious services and actually and regularly engage in religious, benevolent, charitable or educational ministrations or the performance of hefor health care decisions unless: (1) Related to the principal by blood, marriage or adoption; or (2) the principal and agent are members of the same community of persons who are bound by vows to a re an employee, owner, director or officer of a facility described [in] subsection (a)(2) in K.S.A. 58-629 may be designated as the agent to make health care decisions under a durable power of attorney esires of the principal. (d) Neither the treating health care provider, as defined by subsection (c) of K.S.A. 65-4921 and amendments thereto, nor an employee of the treating health care provider, noromination of which the principal is a member. (c) In exercising the authority under the durable power of attorney for health care decisions, the agent has a duty to act consistent with the expressed diding treatment by spiritual means through prayer alone and care consistent therewith, in lieu of medical care and treatment, in accordance with the tenets and practices of any church or religious den-28,102 and amendments thereto, unless the durable power of attorney for health care decisions specifically provides otherwise. Nothing in this act shall be construed as prohibiting an agent from prov conveyed pursuant to this section shall be effective until the occurrence of the principal's impairment as determined by the principal's attending physician, as defined in subsection (a) of K.S.A. 65attorney for health care decisions, and shall not include the power to revoke or invalidate a previously existing declaration by the principal in accordance with the natural death act. No agent powers any releases of other documents that may be required in order to obtain such information. (b) The powers of the agent herein shall be limited to the extent set out in writing in the durable power of -1- (3) request, receive and review any information, verbal or written, regarding the principal's personal affairs or physical or mental health including medical and hospital records and to executefied, or otherwise authorized or permitted by the laws of this state to administer health care as the agent shall deem necessary for the physical, mental and emotional well being of the principal; andg home or similar institution; to employ or discharge health care personnel to include physicians, psychiatrists, psychologists, dentists, nurses, therapists or any other person who is licensed, certiout organ donation, autopsy, and disposition of the body; (2) make all necessary arrangements for the principal at any hospital, psychiatric hospital or psychiatric treatment facility, hospice, nursin the authority to: (1) Consent, refuse consent, or withdraw consent to any care, treatment, service or procedure to maintain, diagnose or treat a physical or mental condition, and to make decisions ab on agent's power; persons not to be designated as agents; witnesses and acknowledgment; effect of death of principal. (a) A durable power of attorney for health care decisions may convey to the agentle notwithstanding the principal's subsequent disability or incapacity. Chapter 58.--PERSONAL AND REAL PROPERTY Article 6.--POWERS AND LETTERSOF ATTORNEY 58-629. Same; authority of agent; limitationsr health care decisions shall become effective upon the disability or incapacity of the principal," or similar words showing the intent of the principal that the authority conferred shall be exercisabriting and the writing contains the words "this power of attorney for health care decisions shall not be affected by subsequent disability or incapacity of the principal" or "this power of attorney fopower of attorney for health care decisions; meaning. A durable power of attorney for health care decisions is a power of attorney by which a principal designates another as the principal's agent in wful excerpts from the Kansas Statutes relating to the Kansas Power of Attorney for Health Care Form. Chapter 58.--PERSONAL AND REAL PROPERTY Article 6.--POWERS AND LETTERSOF ATTORNEY 58-625. Durable r Health Care Decisions (Power of Attorney for Health Care) Form. This Kansas Power of Attorney for Health Care is based on Kansas Statutes Chapter 58 Article 6 et. Seq. (58-632) The following are use Care This package contains (1) Information and Instruction for Kansas Durable Power of Attorney for Health Care Decisions (Power of Attorney for Health Care) ; (2) Kansas Durable Power of Attorney foa tax professional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Information and Instructions Kansas Power of Attorney for Healthparticular situation. Advice from a local attorney is always recommended when dealing with estate planning matters. Any possible tax consequences arising out of this document should be discussed with aws vary from time to time and from state to state. These forms should only be a starting point for you and should not be used or signed without consulting an attorney first to make sure it fits your de or are provided as to their suitability for any specific purpose or as to their legal effect or completeness. [_]These forms are not intended and are not a substitute for legal and/or tax advice. L Care Directive. The first form is the Power of Attorney for Health Care and the second form is the Living Will. [_] These forms are provided "as is" and no implied or express warranties have been maKansas Advance Health Care Directive This package contains both a Kansas Power of Attorney for Health Care and a Kansas Living Will. Together these forms are also sometimes known as an Advance Health Kansas