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Kansas _________________________ (Signature of notary public) (Seal, if any) My appointment expires:__________________________ 2 KANSAS ) )SS. COUNTY OF ________________________ ) This instrument was acknowledged before me on ____________________________ (date) by _________________________________ (name of person) ____________________________________ _____________________________________________ (Witness Signature) Print Name: ___________________________________ Address: ______________________________________ (OR) STATE OF rectly financially responsible for Declarant's medical care. _____________________________________________ (Witness Signature) Print Name: ___________________________________ Address: _______________ted 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 codicil thereto, or di. 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 Declarant. I am not relaf 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) acknowledged before a notary publicon 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 according to the laws o_____________ (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 who signed the declarati_________________ Address: __________________________________________________________________ ______________________________________ Zip Code: ___________________________ ____________________________________________________ I understand the full import of this declaration and I am emotionally and mentally competent to make this declaration. Name: ________________________________________________________________________________________________________________________ ____________________________________________________________________________ _____________________________________________________se medical or surgical treatment and accept the consequences from such refusal. Additional Instructions (optional): ____________________________________________________________________________ _______rections 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 my legal right to refumitted 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 my ability to give die 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 withdrawn, and that I be perby 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-sustaining procedures arll 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 a terminal condition laration made this ___________ day of ______ (month, year). I, __________________________________________________, being of sound mind, willfully and voluntarily make known my desire that my dying shais document should be discussed with a tax professional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Living Will DECLARATION Decrney first to make sure it fits your particular situation. Advice from a local attorney is always recommended when dealing with estate planning matters. Any possible tax consequences arising out of thtitute for legal and/or tax advice. Laws vary from time to time and from state to state. These forms should only be a starting point for you and should not be used or signed without consulting an attoed or express warranties have been made or are provided as to their suitability for any specific purpose or as to their legal effect or completeness. [_]These forms are not intended and are not a subs be given effect without the invalid direction, and to this end the directions in the declaration are severable. Information & Instructions ­ Page 2 [_] These forms are provided "as is" and no implibut in addition may include other specific directions. Should any of the other specific directions be held to be invalid, such invalidity shall not affect other directions of the declaration which caning 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 form, 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. An attendfor 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 courseed 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 responsible ears 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, entitlaking 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 least 18 ydeclaration 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 person m3. 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 execute a s 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 65-28,10Information 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 Statute Kansas