$49.95

Add to cart

Louisiana -5- parish / county and state aforesaid, this __________ day of ________________________________________________ , __________. ______________________________________________________________ Notary Public__________________________ State: ___________________________________ STATE OF LOUISIANA, COUNTY / PARISH OF _________________________: SWORN TO AND SUBSCRIBED before me, Notary Public in and for the____ City: __________________________________ State: ___________________________________ Witness Signature: ___________________________________ Name: ___________________________________ City: ________ate), at _______________________ (city), Louisiana. ________________________________ Signature of Principal Witness Signature: ___________________________________ Name: _______________________________r 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 ________________ (dd 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 good faith and/or of attorney. If this Durable 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 termination, shall be hels 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 reliance on this powe(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 not effective aextent 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 Agent; and/or 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 limited to the 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 reasons for theers 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 under applicable unting for all funds handled and all acts performed as my Agent. This Power of Attorney shall be construed as broadly as a General Power of Attorney. The listing of specific terms, rights, acts or powed 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 shall provide an accol doctor. 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 shall also be entitla lack of capacity to receive and evaluate information effectively, to communicate decisions, and/or to manage my financial resources and affairs properly, as certified in writing by a licensed medicattorney shall not terminate on my subsequent disability, incapacity or lack of mental competence, except as provided by any applicable statute. As used herein, "disability" or "incapacity" shall mean or incapacity as certified in writing by a licensed medical doctor. The rights, powers, and authority of this document shall remain in full force and effect thereafter until my death. This Power of Ahe disclaimed assets pass directly or indirectly to my Agent or my Agent's estate. This Durable Power of Attorney and all rights and powers therein shall become effective upon my subsequent disabilityd 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 entitled, if the result is that t 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), which might be transferre 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 transfer any of my assets to thete, (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 of my assets to discharge anyocument, (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 estaion 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 specifically authorized by this dct 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 federal gift tax annual exclusle 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 the Uniform Gifts to Minors Aions 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 otherwise, and if necessary, to fiormation 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 contribut 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 documents; to obtain or provide infriate, 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 file any documents with anyain 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 assistance as may be appropor 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 other investments. 12. To maint 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, and to examine, remove, keep 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. Treasury Securities. -2- 10. Tong any checks 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 stitutions; 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 endorsiuding, but not limited to, checking accounts, savings accounts, certificates of deposit, investment accounts, brokerage accounts, retirement plan accounts, and other similar accounts with financial iny 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/or close bank accounts, inclide information, 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 securite from any annuity, pension, retirement benefits, retirement plans, insurance benefits and government program including, but not limited to, Social Security and Medicare; to prepare applications, prove 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 recover all payments I receivbecome 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, including life insurance upon my lif 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 receive all monies which may ver, 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 right to sell or encumber anyair, 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 personal property or asset whatsoe, 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, sell, mortgage, improve, rep of action, 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 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 papers, checks, drafts, causesas 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 settle any claim, against me orss, evidences 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 commercial 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 loes, deeds, options, trust deeds, security agreements, leases, mortgages, notes, insurance policies, receipts, title documents, checks, drafts, letters of credit, stock certificates, proxies, warrants,reement 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, conveyancge 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, endorse and execute any written agutes, 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 limited to: 1. To conduct, engas, 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 Agent's substitute or substitand 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, transaction, thing, businesdress at: _____________________________________________________ as my alternate or successor Agent, as necessary, to serve with the same powers, rights and discretions. My Agent shall have full power true and lawful attorney-in-fact for me and in my name, and in my behalf. If the above named Agent is unable to serve for any reason, I appoint _____________________________________ maintaining an ad______________________________________ do hereby make and appoint ________________________________________ ("Agent") maintaining an address at: _____________________________________________________ myagent. -3- LOUISIANA DURABLE POWER OF ATTORNEY Effective upon Disability KNOW ALL PERSONS BY THESE PRESENTS: I, ____________________________________ ("Principal") maintaining an address at _________ for 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 ument, 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 decisionse 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 docted 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 handls 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 grannt will deal with any real estate in Florida. Please note that this information is not intended as and is not a substitute for legal advice. Furthermore, this information is general information that ided 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. Two witnesses are necessary, if the Agedealing 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 Power of Attorney to be recorhe original Agent is unable to serve or continue to serve as the Agent. A Durable Power of Attorney should always be notarized, even if your state does not require it, especially if the Agent will be this Durable Power of Attorney takes effect only after the Principal becomes disabled or incompetent, an alternate Agent can be designated, at the time this Power of Attorney is signed, in the event tally important if the Principal is incapacitated when the Power of Attorney goes into effect, or the Agent undertakes the acts. The Principal can revoke a Durable Power of Attorney at any time. Since powerful" instrument and should be granted with care. Any action undertaken by the Agent, within the scope of the Power of Attorney document, will be legally binding upon the Principal. This is especilawyer". 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. A Power of Attorney is a ", even if the Principal later becomes incapacitated. This particular Form becomes effective upon the disability or incapacity of the Principal. Note that the word "attorney" is not used here to mean " Power of Attorney allows a natural "mentally competent " person (called the "Principal" or "Principal") to authorize someone else (called the "Agent" or "AttorneyIn-Fact") to act on his or her behalfrty. [_] The purchase and use of these forms, is subject to the Disclaimers and Terms of Use found at findlegalforms.com -1- Information Durable Power of Attorney Effective upon Disability A Durableice. These forms should only be a starting point for you and should not be used without consulting with an attorney first. An Attorney should be consulted before negotiating a document with another pave or continue to serve as the Agent. This section can be removed, deleted (and initialed) or the words "no one" can be entered. [_] These forms are not intended and are not a substitute for legal adv power to handle business and legal matters on the Principal's behalf. [_] This document offers the option of nominating an alternate Agent in the event that the first choice as Agent is unable to ser 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 Agent has thehould 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 attorney-in-fact)g 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. [_] The Principal sa 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 be dealin of 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 2) 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 DisabilityInstructions & Checklist Louisiana Durable Power of Attorney Effective upon Disability [_] This package contains (1) Instructions & Checklist for Durable Power of Attorney Effective upon Disability; ( LouisianaLouisiana of which the person(s) acted, executed the instrument. WITNESS my hand and official seal. Signature __________________________________ (Seal) t and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf________________________________ ___________, personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrumen__________ before me, (here insert name and title of the officer), personally appeared ________________________________________________________________________ ________________________________________________ Names of institutions/individuals who have been provided a copy of this revocation: Notary Acknowledgment State of __________________________ County of ________________________ ) ) ss ) On ______ State:_________________________ Witness Signature:__________________ Date: ___________________________ Name: ___________________________ City: _________________________ State:_________________ ___________________ (date). _____________________________ Principal Witness Signature:__________________ Date: ___________________________ Name: ___________________________ City: ___________________ artificial life sustaining procedures is revoked and withdrawn and this document provides notice of such revocation. IN WITNESS WHEREOF, I have signed this Health Care Power of Attorney Revocation on______________________________ (title of document(s)) dated __________________ and all power and authority granted thereby including powers for making health care decisions on my behalf and concerningRevocation I, ___________________________________ (Principal) maintaining an address at __________________________________________________ (address of Principal), hereby revoke my ____________________ion that is not state specific. Whenever appropriate, the instructions included with the forms packages offered for sale, generally include state specific instructions. Health Care Power of Attorney revoked. This revocation becomes effective immediately. Please note that this information is not intended as and is not a substitute for legal advice. Furthermore, this information is general informate Power of Attorney Revocation is used by the Grantor to give notice that a previously granted Health Care Power of Attorney (sometimes referred to as a Living Will or Health Care Directive) has been alth Care Power of Attorney Revocation If the Grantor of a Health Care Power of Attorney decides to revoke the document, it is almost always required that the revocation be in writing. The Health Carfor you and should not be used without consulting with an attorney first. The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Information Hetify both. These forms are not intended and are not a substitute for legal advice. Laws are different from state to state and may change from time to time. These forms should only be a starting point e revocation document. If more than one document is being revoked, then each document needs to be identified i.e. if you are revoking a Health Care Power of Attorney and a Living Will, be sure to idenpies of the Health Care Power of Attorney so as to avoid any questions about the revocation or its effectiveness. The exact full title of the document(s) that you are revoking should be inserted in thon. In the event the original power of attorney was filed publicly (i.e. recorded), then the notice of revocation should also be filed publicly, in the same manner. The Principal should destroy any coceived a copy of the original Power of Attorney or who may have dealt with the Agent acting on behalf of the Principal. It is a good idea to keep a record of anyone who was sent a copy of the revocatio the Principal, the Agent or the Notary should not be a witness. The Principal should keep a copy of the revocation in his/her files. Copies of the revocation should be sent to anyone who may have reough not always required, it is always a good idea to also have two witnesses sign the Revocation of Power of Attorney. The witnesses should be adults. Generally, anyone related by blood or marriage tified mail receipt, delivery receipt etc..). Any health care providers need to be given a copy of the Revocation as well and copies of the revocation should be kept in any relevant medical files. Alth show that it was the Grantor's intent to revoke the Power of Attorney. If possible, the Principal should keep a copy of any document showing that the Agent received the original revocation (i.e. certd. Notarization is also necessary to record the revocation. This revocation becomes effective immediately. The original or a copy of the revocation must be given to the Agent (i.e. Attorney-inFact) tohe Health Care Power of Attorney Revocation before a Notary even if it is not required. Notarization will also help to ensure that the revocation is effective and support its authenticity if challengeer of Attorney Revocation (3) Health Care Power of Attorney Revocation The Principal (i.e. the person granting the Health Care Power of Attorney Revocation; sometimes called the Grantor) should sign tInstructions & Checklist Health Care Power of Attorney Revocation This package includes (1) Checklist & Instructions for Health Care Power of Attorney Revocation (2) Information about Health Care Pow LouisianaLouisiana ___________________________________________ (Witness Signature) _______________________________________________________ (Witness Signature) e) _______________________________________________________ City, Parish and State of Residence The declarant has been personally known to me and I believe him or her to be of sound mind. ____________al. I understand the full import of this declaration and I am emotionally and mentally competent to make this declaration. _______________________________________________________ (Declarant's Signaturntion that this declaration shall be honored by my family and physician(s) as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences from such refusrformance of any medical procedure deemed necessary to provide me with comfort care. In the absence of my ability to give directions regarding the use of such life-sustaining procedures, it is my intend hydration, be withheld or withdrawn so that food and water can be administered invasively. I further direct that I be permitted to die naturally with only the administration of medication or the pefe-sustaining procedures, including nutrition and hydration, be withheld or withdrawn so that food and water will not be administered invasively. ___That life-sustaining procedures, except nutrition at life-sustaining procedures are utilized and where the application of life-sustaining procedure would serve only to prolong artificially the dying process, I direct (initial one only): ___That all linal and irreversible 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 noand do hereby declare: If at any time I should have an incurable injury, disease or illness, or be in a continual profound comatose state with no reasonable chance of recovery, certified to be a termimonth, year). I, _______________________, being of sound mind, willfully and voluntarily make known my desire that my dying shall not be artificially prolonged under the circumstances set forth below ional. The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Living Will DECLARATION Declaration made this _______________ day of __________ (tuation. 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 a tax profess 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 particular siprovided as to their suitability for any specific purpose or as to their legal effect or completeness. These forms are not intended and are not a substitute for legal and/or tax advice. Laws vary from any physician or health care facility acting in good faith may rely upon the validity of the declaration. These forms are provided "as is" and no implied or express warranties have been made or are n that office. The secretary of state shall indicate on the declaration the date and time the notice of revocation was received in his office. Until the notation has been indicated on the declaration,ds the time and date when notification of the revocation was received. B. A declaration registered with the secretary of state's office may be revoked by the filing of a written notice of revocation i) Such revocation by any method enumerated in this Section shall become effective upon communication to the attending physician. (c) The attending physician shall record in the patient's medical recorient's medical record the time and date when notification of the written revocation was received. (3)(a) By an oral or nonverbal expression by the declarant of the intent to revoke the declaration. (b) By a written revocation of the declarant expressing the intent to revoke, signed and dated by the declarant. Information & Instructions ­ Page 5 (b) The attending physician shall record in the patfollowing methods: (1) By being cancelled, defaced, obliterated, burned, torn, or otherwise destroyed by the declarant or by some person in the presence of and at the direction of the declarant. (2)(a a copy or facsimile thereof. §1299.58.4. Revocation of declaration A. A declaration may be revoked at any time by the declarant without regard to his or her mental state or competency by any of the five dollars for filing a notice of revocation. No charge shall be made for the furnishing of information concerning the existence of a declaration, the disclosure of its contents, or the providing ofatment or life-sustaining procedures. (3) The secretary of state may charge a fee of twenty dollars for registering a declaration and issuing a do-not-resuscitate identification bracelet and a fee of hentic. However, nothing herein requires a physician or health care facility to confirm the existence of such declaration or obtain a copy thereof prior to the withholding or withdrawal of medical tre the contents thereof for any patient believed to be a resident of Louisiana. A copy of the declaration or a facsimile thereof transmitted from the office of the secretary of state shall be deemed autDO NOT RESUSCITATE". (2) Any attending physician or health care facility may, orally or in writing, request the secretary of state to confirm immediately the existence of a declaration and to disclosedo-not-resuscitate identification bracelet to qualified patients listed in the registry. The do-not-resuscitate identification bracelet must include the patient's name, date of birth, and the phrase "n which a person, or his attorney, if authorized by the person to do so, may register the original, multiple original, or a certified copy of the declaration. (b) The secretary of state shall issue a invalid for that reason nor presumed to mean that the declarant desires the invasive administration of nutrition or hydration. D.(1)(a) The secretary of state shall establish a declaration registry ilearly provides to the contrary. (b) Any declaration executed prior to August 15, 2005, which does not contain an option to specifically initial a choice regarding nutrition and hydration shall not bent is in a continual profound comatose state shall not be invalid for that reason. Such declaration shall be applicable to any terminal and irreversible condition, as defined in this Part, unless it cections in the declaration are severable. (3)(a) Any declaration executed prior to January 1, 1992, which does not contain directions regarding life-sustaining procedures in the event that the declarae other specific directions be held to be invalid, such invalidity shall not affect other directions of the declaration which can be given effect without the invalid direction, and to this end the diruld he be diagnosed as having a terminal and irreversible condition and be comatose, incompetent, or otherwise mentally or physically incapable of communications: (included below) (2) Should any of thd not, be in the following illustrative form and may include other specific directions including but not limited to a designation of another person to make the treatment decision for the declarant shothe reasons the declarant could not make a written declaration and make the recitation a part of the patient's medical records. Information & Instructions ­ Page 4 C.(1) The declaration may, but neen, or a notation of the existence of a registered declaration, a part of the declarant's medical record. (4) If the declaration is oral or nonverbal, the physician shall promptly make a recitation of n who is so notified, or who determines directly or is advised by the health care facility that a declaration is registered, shall promptly make the declaration or a copy of the declaration, if writtestence of the declaration. In addition, the attending physician or health care facility may directly contact the registry to determine the existence of any such declaration. (3) Any attending physiciadeclaration has been made. (2) In the event the declarant is comatose, incompetent, or otherwise mentally or physically incapable of communication, any other person may notify the physician of the eximeans of communication at any time subsequent to the diagnosis of a terminal and irreversible condition. B.(1) It shall be the responsibility of the declarant to notify his attending physician that a written declaration shall be signed by the declarant in the presence of two witnesses. (3) An oral or nonverbal declaration may be made by an adult in the presence of two witnesses by any nonwritten son may, at any time, make a written declaration directing the withholding or withdrawal of life-sustaining procedures in the event such person should have a terminal and irreversible condition. (2) Ae to be withheld or withdrawn upon his decease. 1299.58.3. Making of declaration; notification; illustrative form; registry; issuance of donot-resuscitate identification bracelets A.(1) Any adult pered to the declarant or qualified patient, whichever is applicable, by blood or marriage and who would not be entitled to any portion of the estate of the person from whom life-sustaining procedures arical judgment, would produce death and for which the application of life-sustaining procedures would serve only to postpone the moment of death. (16) "Witness" means a competent adult who is not relat "Terminal and irreversible condition" means a continual profound comatose state with no reasonable chance of recovery or a condition caused by injury, disease, or illness which, within reasonable meduse, that has resulted in the terminal and irreversible condition as defined in Paragraph (15) of this Section, or who has violated any domestic abuse protective order affecting the other spouse. (15)ially separated from the patient, is cohabited with another person in the manner of married persons, or who has been convicted of any crime of violence as defined in R.S. 14:2(B) against the other spoions established and maintained by the secretary of state pursuant to this Part. (14) "Spouse" means a person who is legally married to the qualified patient but does not include a spouse who is judic as having a terminal and irreversible condition by two physicians who have personally examined the patient, one of whom shall be the attending physician. (13) "Registry" means a registry for declaratte Board of Medical Examiners or by the official licensing authority of another state. Information & Instructions ­ Page 3 (12) "Qualified patient" means a patient diagnosed and certified in writingl not include any measure deemed necessary to provide comfort care. (10) "Minor" means a person under eighteen years of age. (11) "Physician" means a physician or surgeon licensed by the Louisiana Sta irreversible condition, including such procedures as the invasive administration of nutrition and hydration and the administration of cardiopulmonary resuscitation. A "life-sustaining procedure" shalstaining procedure" means any medical procedure or intervention which, within reasonable medical judgment, would serve only to prolong the dying process for a person diagnosed as having a terminal andized bracelet as described in R.S. 40:1299.58.3(D)(1)(b). (8) "Health care provider" means any health maintenance organization, home health agency, hospice, hospital, or nursing facility. (9) "Life-suorally, or by other means of nonverbal communication. (6) "Declarant" means a person who has executed a declaration as defined herein. (7) "Do-not-resuscitate identification bracelet" means a standardion voluntarily made by the declarant, authorizing the withholding or withdrawal of life-sustaining procedures, in accordance with the requirements of this Part. A declaration may be made in writing, nd adopted by the bureau of emergency medical services of the Department of Health and Hospitals and who is certified by the bureau. (5) "Declaration" means a witnessed document, statement, or expressdefined in R.S. 40:1231. (4) "Certified first responder" means any person who has successfully completed a training course developed and promulgated by the United States Department of Transportation ad to restore or support cardiac or respiratory function in the event of a cardiac or respiratory arrest. (3) "Certified emergency medical technician" means a certified emergency medical technician as y states otherwise: (1) "Attending physician" means the physician who has primary responsibility for the treatment and care of the patient. (2) "Cardiopulmonary resuscitation" means those measures usehe application of medical treatment or life-sustaining procedures. §1299.58.2. Definitions As used in this Part, the following words shall have the meanings ascribed to them unless the context clearln, nor shall this Part be construed to require the application of medically inappropriate treatment or life-sustaining procedures to any patient or to interfere with medical judgment with respect to ton pursuant to this Part. (3) It is the intent of the legislature that nothing in this Part shall be construed to be the exclusive means by which life-sustaining procedures may be withheld or withdraw withholding or withdrawal of medical treatment or life-sustaining procedures. (2) It is the intent of the legislature that nothing in this Part shall be construed to require the making of a declaratihis Part are permissive and voluntary. The legislature further intends that the making of a declaration pursuant to this Part merely illustrates a means of documenting a patient's decision relative todical judgment with respect to the application of medical treatment or life-sustaining procedures. Information & Instructions ­ Page 2 B. Intent. (1) The legislature intends that the provisions of tures may be withheld or withdrawn, nor shall this Part be construed to require the application of medically inappropriate treatment or life-sustaining procedures to any patient or to interfere with mee condition. (4) In furtherance of the rights of such persons, the legislature finds and declares that nothing in this Part shall be construed to be the exclusive means by which life-sustaining proced, incompetent, or otherwise physically or mentally incapable of communication, or from a minor, in the event such adult patient or minor is diagnosed and certified as having a terminal and irreversiblnd irreversible condition; and (b) The right of certain individuals to make a declaration pursuant to which lifesustaining procedures may be withheld or withdrawn from an adult patient who is comatosesician to withhold or withdraw life-sustaining procedures or designating another to make the treatment decision and make such a declaration for him, in the event he is diagnosed as having a terminal aly in decisions concerning themselves, the legislature hereby declares that the laws of the state of Louisiana shall recognize: (a) The right of such a person to make a declaration instructing his phyxistence while providing nothing medically necessary or beneficial to the person. (3) In order that the rights of such persons may be respected even after they are no longer able to participate activee artificial prolongation of life for a person diagnosed as having a terminal and irreversible condition may cause loss of individual and personal dignity and secure only a precarious and burdensome ecision to have life-sustaining procedures withheld or withdrawn in instances where such persons are diagnosed as having a terminal and irreversible condition. (2) The legislature further finds that thurpose, findings and intent A. Purpose and findings. (1) The legislature finds that all persons have the fundamental right to control the decisions relating to their own medical care, including the den Title 40 Section 1299.58.1 et. seq. of the Louisiana Statutes. For your convenience, we have included useful excerpts from the Louisiana Statutes relating to Living Wills. §1299.58.1. Legislative pInformation and Instructions Louisiana Living Will This packet includes: (1) Information and Instruction for Louisiana Living Will; and (2) Louisiana Living Will. This Louisiana Living Will is based o LouisianaLouisiana I believe him or her to be of sound mind. Witness ______________________________________________________ Witness ______________________________________________________ tally competent to make this declaration. Signed ___________________________________________ City, Parish and State of Residence ____________________ The declarant has been personally known to me and lling to act on my behalf, my declaration will nevertheless be given effect should the above-discussed circumstance arise. I understand the full import of this declaration and I am emotionally and menagent and alternate agent named above, and I trust his/her judgment on my behalf. I understand that if I have not filled in any name in this clause or if the agent I have chosen is unavailable or unwiilling or unavailable to act, by my successor attorney-in-fact, unless the attending physician determines that I have decisional capacity. I have discussed my desires concerning terminal care with my and is not affected by physical disability or mental incompetence. The determination of whether I can make my own medical decisions is to be made by my attorney-in-fact, or if he or she is unable, unwey-in-fact) _____________________________________________ (telephone number of successor attorney-in-fact) This power of attorney becomes effective when I can no longer make my own medical decisions, ney-in-fact, I hereby appoint: _______________________________________________________ (name of successor attorney-in-fact) _______________________________________________ (address of successor attornersible condition and (2) comatose, incompetent or otherwise mentally or physically incapable of communication. In the event the person I appoint is unable, unwilling or unavailable to act as my attor all medical treatment decisions for me, including decisions to withhold or withdraw any form of life-sustaining procedure on my behalf should I be (1) diagnosed as suffering from a terminal and irrev______________________________________________ (address of attorney-infact) ______________________________________________________ (telephone number of attorney-in-fact) as my attorney-in-fact to make_____________________________________________________, being of sound mind, willfully and voluntarily appoint: ___________________________________________________ (name of attorney-in-fact) __________forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com -4- Power of Attorney for Health Care Declaration made this _______________ day of __________ (month, year). I, _____y whenever a document is negotiated with another party. Any -3- possible tax consequences arising out of this document should be discussed with a tax professional. [_] The purchase and use of these ithout consulting with an attorney first. Before 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 attorneare 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 not be used ws 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. [_]These forms received in his office. Until the notation has been indicated on the declaration, any physician or health care facility acting in good faith ` rely upon the validity of the declaration. [_] These formf state's office may be revoked by the filing of a written notice of revocation in that office. The secretary of state shall indicate on the declaration the date and time the notice of revocation was hysician. (c) The attending physician shall record in the patient's medical records the time and date when notification of the revocation was received. B. A declaration registered with the secretary ononverbal expression by the declarant of the intent to revoke the declaration. (b) Such revocation by any method enumerated in this Section shall become effective upon communication to the attending p and dated by the declarant. (b) The attending physician shall record in the patient's medical record the time and date when notification of the written revocation was received. (3) (a) By an oral or therwise destroyed by the declarant or by some person in the presence of and at the direction of the declarant. (2) (a) By a written revocation of the declarant expressing the intent to revoke, signedon may be revoked at any time by the declarant without regard to his or her mental state or competency by any of the following methods: (1) By being cancelled, defaced, obliterated, burned, torn, or ornishing of information concerning the existence of a declaration, the disclosure of its contents, or the providing of a copy or facsimile thereof. §1299.58.4. Revocation of declaration A. A declaratiwenty dollars for registering a declaration and issuing a do-not-resuscitate identification brace` and a fee of five dollars for filing a -2- notice of revocation. No charge shall be made for the fum the existence of such declaration or obtain a copy thereof prior to the withholding or withdrawal of medical treatment or life-sustaining procedures. (3) The secretary of state may charge a fee of tf the declaration or a facsimile thereof transmitted from the office of the secretary of state shall be deemed authentic. However, nothing herein requires a physician or health care facility to confirr in writing, request the secretary of state to confirm immediately the existence of a declaration and to disclose the contents thereof for any patient believed to be a resident of Louisiana. A copy oy. The do-not-resuscitate identification bracelet must include the patient's name, date of birth, and the phrase "DO NOT RESUSCITATE". (2) Any attending physician or health care facility may, orally othe original, multiple original, or a certified copy of the declaration. (b) The secretary of state shall issue a do-not-resuscitate identification bracelet to qualified patients listed in the registrss it clearly provides to the contrary. D. (1) (a) The secretary of state shall establish a declaration registry in which a person, or his attorney, if authorized by the person to do so, may register declarant is in a continual profound comatose state shall not be invalid for that reason. Such declaration shall be applicable to any terminal and irreversible condition, as defined in this Part, unleend the directions in t` declaration are severable. (3) Any declaration executed prior to January 1, 1992, which does not contain directions regarding life sustaining procedures in the event that the ld any of the other specific directions be held to be invalid, such invalidity shall not affect other directions of the declaration which can ` given effect without the invalid direction, and to this should he be diagnosed as having a terminal and irreversible condition and be comatose, incompetent, or otherwise mentally or physically incapable of communications (see form enclosed below): (2) Shouneed not, be in the following illustrative form and may include other specific directions including but not limited to a designation of another person to make the treatment decision for the declarant ian shall promptly make a recitation of the reasons the declarant could not make a written declaration and make the recitation a part of the patient's medical records. C. (1) The declaration may, but copy of the declaration, if written, or a notation of the existence of a registered declaration, a part of the declarant's medical record. -1- (4) If the declaration is oral or nonverbal, the physicaration. (3) Any attending physician who is so notified, or who determines directly or is advised by the health care facility that a declaration is registered shall promptly make the declaration or a may notify the physician of the existence of the declaration. In addition, the attending physician or health care facility may directly contact the registry to determine the existence of any such declify his attending physician that a declaration has been made. (2) In the event the declarant is comatose, incompetent, or otherwise mentally or physically incapable of communication, any other person f two witnesses by any nonwritten means of communication at any time subsequent to the diagnosis of a terminal and irreversible condition. B. (1) It shall be the responsibility of the declarant to not and irreversible condition. (2) A written declaration shall be signed by the declarant in the presence of two witnesses. (3) An oral or nonverbal declaration may be made by an adult in the presence oion bracelets A. (1) Any adult person may, at any time, make a written declaration directing the withholding or withdrawal of life-sustaining procedures in the event such person should have a terminalisiana Statutes relating to the Louisiana Power of Attorney for Health Care Form. 1299.58.3. Making of declaration; notification; illustrative form; registry; issuance of donot-resuscitate identificatttorney for Health Care Form. This Louisiana Power of Attorney for Health Care is based on Title 40 Section 1299.58.3 et. Seq. of the Louisiana Statutes. The following are useful excerpts from the LouInformation and Instructions Louisiana Power of Attorney for Health Care This package contains (1) Information and Instruction for Louisiana Power of Attorney for Health Care; (2) Louisiana Power of A LouisianaLouisiana _________________ Name: _______________________________________________ Address: ____________________________________________ City: _______________________________________________ State: ______________________________: _______________________________________________ State: _______________________________________________ SECOND WITNESS: Date: __________________ Signature: ___________________________________________ITNESS: Date: __________________ Signature: ___________________________________________ Name: _______________________________________________ Address: ____________________________________________ Cityion and in the presence of the Donor and each other. The individual signing the Donation of Gift was directed to do so by the Donor and signed the document in his/her presence as well as ours. FIRST Wnd by two witnesses, all of whom have signed at the direction and in the presence of the donor and of each other, and state that it has been so signed.] Witness Statement: We have signed at the direct____________________ WITNESS FORM [An anatomical gift may be made only by a document of gift signed by the donor. If the donor cannot sign, the document of gift must be signed by another individual a_ Print your name: ______________________________________ Address: ____________________________________________ City: _______________________________________________ State: ___________________________n, surgeon, technician, or enucleator to carry out the appropriate procedures. SIGNATURE: (Sign and date the form here:) Date: __________________ Sign your name: _____________________________________the appropriate procedures. In the absence of a designation or if the designee is not available, the donee or other person authorized to accept the anatomical gift may employ or authorize any physiciaof the following you do not want): (1) Transplant (2) Therapy (3) Research (4) Education (Optional) I designate ___________________________________ as my particular physician or surgeon to carry out __ ________________________________________________________________________ ________________________________________________________________________ My gift is for the following purposes (strike any x): Give any needed organs, tissues, or parts, OR Give the following organs, tissues, or parts only: ____________________________ ______________________________________________________________________ for all serious legal matters. Anatomical Gift by Living Donor Pursuant to Uniform Anatomical Gift Act Upon my death, I ____________________________________ (the "Donor"), hereby (mark applicable boand on any theory of liability, whether in contract, strict liability, or tort (including negligence or otherwise) arising in any way out of the use of these materials. An attorney should be consultedntal, special, exemplary, or consequential damages (including, but not limited to, procurement of substitute goods or services; loss of use, data, or profits; or business interruption) however caused risk. In no event will: i) FindLegalForms, Inc, its agents, partners, or affiliates, or ii) the providers, authors or publishers of the forms, be responsible or liable for any direct, indirect, incideovided "AS-IS." We do not give any express or implied warranties of merchantability, suitability or completeness for any of the materials for your particular needs. The materials are used at your own erials. FindLegalForms, Inc. does not provide legal advice. The purchase and use of these materials is subject to the "Disclaimers and Terms of Use" found at findlegalforms.com. These materials are pran anatomical gift. During a terminal illness or injury, the refusal may be an oral statement or other form of communication. Disclaimer No Attorney-Client relationship is created by use of these matocument of gift, (ii) a statement attached to or imprinted on a donor's motor vehicle operator's or chauffeur's license, or (iii) any other writing used to identify the individual as refusing to make the consent or concurrence of any person after the donor's death. An individual may refuse to make an anatomical gift of the individual's body or part by (i) a writing signed in the same manner as a ddelivery of a signed statement to a specified donee to whom a document of gift had been delivered. An anatomical gift that is not revoked by the donor before death is irrevocable and does not require ) a signed statement; (2) an oral statement made in the presence of two individuals; (3) any form of communication during a terminal illness or injury addressed to a physician or surgeon; or (4) the f, after death, the will is declared invalid for testamentary purposes, the validity of the anatomical gift is unaffected. A donor may amend or revoke an anatomical gift, not made by will, only by: (1ze any physician, surgeon, technician, or enucleator to carry out the appropriate procedures. An anatomical gift by will takes effect upon death of the testator, whether or not the will is probated. In to carry out the appropriate procedures. In the absence of a designation or if the designee is not available, the donee or other person authorized to accept the anatomical gift may employ or authories, all of whom have signed at the direction and in the presence of the donor and of each other, and state that it has been so signed. A document of gift may designate a particular physician or surgeo least 18 years of age. An anatomical gift may be made by a document of gift signed by the donor. If the donor cannot sign, the document of gift must be signed by another individual and by two witness Instructions for preparing your Anatomical Gift Anatomical Gift Form To make an anatomical gift, limit an anatomical gift or refuse to make an anatomical gift, an individual must in most cases be atvides tools and guidelines to assist you in creating your Anatomical Gift and is designed to fulfill the obligations of the Uniform Anatomical Gift Act. Included in this kit are the following: Generalour wishes regarding the disposition of your body will be ignored. By preparing a written Anatomical Gift, you can rest assured that your desire to donate your organs will be carried out. This kit proFindLegalForms.com Information Donation Pursuant to the Uniform Anatomical Gift Act (by Living Donor) No one likes considering their own death, but by avoiding the subject, it is likely that many of y LouisianaLouisiana ________ n whose name is subscribed to this instrument appears to be of sound mind and under no duress, fraud, or undue influence. _____________________________ Notary Public My commission expires ____________ersonally and, under oath, stated that he or she is the person described in the above document and he or she signed the above document in my presence. I declare under penalty of perjury that the perso_________________________________ Notary Acknowledgment (Optional) State of ____________________ County of ____________________ On ____________________, ______________________________ came before me pignature of Donor ______________________________ Printed Name of Donor Address: ____________________________________________ City: _______________________________________________ State: ______________y written revocation of my Anatomical Gift. This statement will be delivered to all specified donees, if any, to whom a document of gift had been previously delivered. ______________________________ Sication during a terminal illness or injury addressed to a physician or surgeon; or (4) the delivery of a signed statement to a specified donee to whom a document of gift had been delivered. This is m of this state, a donor may amend or revoke an anatomical gift, not made by will, only by: (1) a signed statement; (2) an oral statement made in the presence of two individuals; (3) any form of commun__________________, I, ______________________________, the donor, fully and completely revoke the Anatomical Gift dated __________________________. Pursuant to Uniform Anatomical Gift Act and the lawsft Act, you should check the laws of your state to determine whether there are any other requirements you must meet to revoke your Anatomical Gift. Revocation of Anatomical Gift On this date ________estroy the original and all copies of your Anatomical Gift or cross out each page of the forms and mark "REVOKED" across them in bold print. Although most states have adopted the Uniform Anatomical Giorm notarized. You should also make certain that a copy of any revocation is provided to anyone who has a copy of your original Anatomical Gift, including any designated donees. You should also then dted. When you have completed the form and printed it, sign the form and make certain that you store the original where you had stored the original of your Anatomical Gift. You may choose to have the f. An anatomical gift that is not revoked by the donor before death is irrevocable and does not require the consent or concurrence of any person after the donor's death. Complete the information requesm of communication during a terminal illness or injury addressed to a physician or surgeon; or (4) the delivery of a signed statement to a specified donee to whom a document of gift had been deliveredn of Anatomical Gift form. A donor may amend or revoke an anatomical gift, not made by will, only by: (1) a signed statement; (2) an oral statement made in the presence of two individuals; (3) any foray out of the use of these materials. An attorney should be consulted for all serious legal matters. Revoking Your Anatomical Gift Instructions Following these instructions, you will find a Revocatios of use, data, or profits; or business interruption) however caused and on any theory of liability, whether in contract, strict liability, or tort (including negligence or otherwise) arising in any w the forms, be responsible or liable for any direct, indirect, incidental, special, exemplary, or consequential damages (including, but not limited to, procurement of substitute goods or services; loserials for your particular needs. The materials are used at your own risk. In no event will: i) FindLegalForms, Inc, its agents, partners, or affiliates, or ii) the providers, authors or publishers ofand Terms of Use" found at findlegalforms.com. These materials are provided "AS-IS." We do not give any express or implied warranties of merchantability, suitability or completeness for any of the matlaimer No Attorney-Client relationship is created by use of these materials. FindLegalForms, Inc. does not provide legal advice. The purchase and use of these materials is subject to the "Disclaimers esigned to fulfill the requirements of the Uniform Anatomical Gift Act. Included in this kit is the following: General Instructions for Revoking Your Anatomical Gift Revocation of Anatomical Gift Discnt to revoke the document. Until your death, it is your right to revoke your Anatomical Gift at any time. This kit provides tools and guidelines to assist you in revoking your Anatomical Gift and is dFindLegalForms.com Information Revoking an Anatomical Gift (Organ Donation Revocation) You prepared a written Anatomical Gift, but now because of a change of circumstances or a change of heart, you wa LouisianaLouisiana _____________ Name of Survivor: _______________________________ Address: ____________________________________________ City: _______________________________________________ State: __________________________________urposes (strike any of the following you do not want): (1) Transplant (2) Therapy (3) Research (4) Education Date: __________________ Signature of Survivor: __________________________________ Printed_______________ ________________________________________________________________________ ________________________________________________________________________ III. The gift is for the following pthe applicable box): Give any needed organs, tissues, or parts, OR Give the following organs, tissues, or parts only: _______________________ _________________________________________________________ity and state). I. I survive the decedent as (mark the appropriate box): spouse; adult son or daughter; parent; adult brother or sister; grandparent; or guardian of the decedent. II. I hereby (mark this anatomical gift from the body of __________________________________(name of decedent) who died on _____________, 20___ at_______________________________ in ____________________________________ (corney should be consulted for all serious legal matters. Anatomical Gift by Next of Kin or Guardian of the Person Pursuant to the Uniform Anatomical Gift Act and the law of this state, I hereby make rruption) however caused and on any theory of liability, whether in contract, strict liability, or tort (including negligence or otherwise) arising in any way out of the use of these materials. An att direct, indirect, incidental, special, exemplary, or consequential damages (including, but not limited to, procurement of substitute goods or services; loss of use, data, or profits; or business inteals are used at your own risk. In no event will: i) FindLegalForms, Inc, its agents, partners, or affiliates, or ii) the providers, authors or publishers of the forms, be responsible or liable for anym. These materials are provided "AS-IS." We do not give any express or implied warranties of merchantability, suitability or completeness for any of the materials for your particular needs. The materieated by use of these materials. FindLegalForms, Inc. does not provide legal advice. The purchase and use of these materials is subject to the "Disclaimers and Terms of Use" found at findlegalforms.con for the removal of a part from the body of the decedent, the physician, surgeon, technician, or enucleator removing the part knows of the revocation. Disclaimer No Attorney-Client relationship is cr a member of the person's class or a prior class. An anatomical gift by a person authorized under subdivision may be revoked by any member of the same or a prior class if, before procedures have beguoposing to make an anatomical gift knows of a refusal or contrary indications by the decedent. (3) The person proposing to make an anatomical gift knows of an objection to making an anatomical gift byAn anatomical gift may not be made by a person listed above if any of the following occur: (1) A person in a prior class is available at the time of death to make an anatomical gift. (2) The person pre decedent; (3) either parent of the decedent; (4) an adult brother or sister of the decedent; (5) a grandparent of the decedent; and (6) a guardian of the person of the decedent at the time of death ker for an authorized purpose, unless the decedent, at the time of death, has made an unrevoked refusal to make that anatomical gift: (1) the spouse of the decedent; (2) an adult son or daughter of th Gift Form An anatomical gift may be made any member of the following classes of persons, in the order of priority listed, may make an anatomical gift of all or part of the decedent's body or a pacemas made on behalf of the decedent by the next of kin or guardian. Included in this kit are the following: General Instructions for preparing your Anatomical Gift (by next of kin or guardian) Anatomicalt. As the next of kin or guardian, you can prepare and execute an Anatomical Gift on behalf of the decedent. This kit is designed to fulfill the obligations of the Uniform Anatomical Gift Act for giftFindLegalForms.com Information Donation Pursuant to the Uniform Anatomical Gift Act (by Next of Kin or Guardian) A loved one has died and you believe that he/she would desire to make an Anatomical Gif Louisiana