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Louisiana ___________________ Notary Public -5- me, Notary Public in and for the parish / county and state aforesaid, this __________ day of ________________________________________________ , __________. ______________________________________________________________ City: __________________________________ State: ___________________________________ STATE OF LOUISIANA, COUNTY / PARISH OF _________________________: SWORN TO AND SUBSCRIBED beforee: ___________________________________ City: __________________________________ State: ___________________________________ Witness Signature: ___________________________________ Name: ________________ent. Signed on ________________ (date), at _______________________ (city), Louisiana. ________________________________ Signature of Principal Witness Signature: ___________________________________ Namfailure to act in good faith and/or willful misconduct, while acting under the authority of this Power of Attorney. I may revoke this Power of Attorney at any time by providing written notice to my Ag of such termination, shall be held harmless. -4- Agent shall not be liable for losses resulting from judgment errors made in good faith. However, Agent will be liable for breach of fiduciary duty, y because of reliance on this power of attorney. If this Durable Power of Attorney is terminated by operation of law, any person relying in good faith on the authority of this document, without noticewer of attorney is not effective as to a third party until the third party has actual knowledge of the revocation. I agree to indemnify the third party for any claims that arise against the third partn on the life of my Agent; and/or (c) my assets to be subject to a general power of appointment by my Agent. Any third party who receives a copy of this document may act under it. Revocation of the poer-of-attorney are limited to the extent necessary to prevent (a) my income to be taxable to my Agent; (b) my Agent to have any rights or ownership with respect to any life insurance policies I may ow inquire as to the reasons for the use or issuance of this power-ofattorney or as to the disposition of any proceeds paid to my Agent based on this document. The powers granted to my Agent by this powor unenforceable under applicable law, then the remaining unaffected parts of the document shall still remain in full force and effect and not be affected by any partial invalidity. No person needs topecific terms, rights, acts or powers are not intended to restrict or limit the definition or scope of powers granted herein in any manner. If any part of this document is held to be invalid, illegal lf, my Agent shall provide an accounting for all funds handled and all acts performed as my Agent. This Power of Attorney shall be construed as broadly as a General Power of Attorney. The listing of sred, my Agent shall also be entitled to reasonable compensation for any services provided as my Agent If so requested by myself or any authorized personal representative or fiduciary acting on my behay financial resources and affairs properly. My Agent shall be entitled to reimbursement of all reasonable expenses incurred as a result of carrying out any provision of this Power of Attorney. If desided by any applicable statute). As used herein, "disability" or "incapacity" shall mean a lack of capacity to receive and evaluate information effectively, to communicate decisions, and/or to manage mcument shall remain in full force and effect thereafter until my death. This Power of Attorney shall not terminate on my subsequent disability, incapacity or lack of mental competence (except as provi-3- This Durable Power of Attorney and the rights, powers, and authority of my Agent shall become effective immediately upon execution of this instrument. The rights, powers, and authority of this doas may be appropriate. However, Agent may not disclaim assets, to which I would be entitled, if the result is that the disclaimed assets pass directly or indirectly to my Agent or my Agent's estate. e of such transfer. 17. To disclaim any interest (subject to other provisions of this document), which might be transferred or distributed to me from any other person, estate, trust, or other entity, y Agent may owe to others, excluding those whom I am legally obligated to support. 16. To transfer any of my assets to the trustee of any revocable trust created by me, if such trust exists at the tim Agent's estate, my Agent's creditors, or the creditors of my Agent's estate, or (c) use any of my assets to discharge any of my Agent's legal obligations, including any obligations of support which m rights, directly or indirectly, to my Agent, my Agent's estate, my Agent's creditors, or the creditors of my Agent's estate, (b) exercise any powers of appointment I may hold in favor of my Agent, mytive and shall lapse at the end of each calendar year. However, my Agent may not, unless specifically authorized by this document, (a) gift, appoint, assign or designate any of my assets, interests orgifts that qualify for the federal gift tax annual exclusion, shall not exceed in value the federal gift tax annual exclusion amount in any one calendar year, and this annual right shall be non-cumulae made to the minor directly or parent, guardian or close friend of the minor or pursuant to the Uniform Gifts to Minors Act or the Uniform Transfers To Minors Act. Any gifts made shall be limited to organizations without regard to whether such gifts are a part of my estate planning or otherwise, and if necessary, to file any state and federal gift tax returns and documents. Gifts to minors may btax matters and to negotiate, compromise or settle any matter with such agency. 15. To make gifts and charitable contributions of my real, personal, tangible or intangible property, to such persons orto, federal, state, local or other income and tax returns and necessary and/or related documents; to obtain or provide information to and from any agency, including governmental agencies, relating to sionals, brokers and real estate agents. 14. To prepare, or cause to be prepared, sign, and/or file any documents with any federal, state, local or other governmental body, including, but not limited may own or have an interest in, in the future. 13. To employ any professional and/or business assistance as may be appropriate, including but not limited to, attorneys, accountants, investment profesproxy rights, with respect to stocks, bonds, debentures, commodities, options or any other investments. -2- 12. To maintain and/or operate any business that I currently own or have an interest in or me alone or in conjunction with any other person, including access to their contents, and to examine, remove, keep or otherwise dispose of the contents. 11. To exercise any and all rights, including or transfer any note, security, or draft of the United States of America, including U.S. Treasury Securities. 10. To have access to any safe deposit box, vault or other storage area owned or leased byts, warrants, money orders, certificates, cashier checks, cash or vouchers payable to me by any person, firm, corporation or political entity; to perform any act necessary to deposit, negotiate, sell with respect to any of my accounts, including, but not limited to, making deposits and withdrawals, negotiating or endorsing any checks or other instruments, obtaining bank statements, passbooks, draff deposit, investment accounts, brokerage accounts, retirement plan accounts, and other similar accounts with financial institutions; to conduct any business with any banking or financial institution tative Payee" for the purpose of receiving Social Security benefits. 9. To open, maintain and/or close bank accounts, including, but not limited to, checking accounts, savings accounts, certificates o its agencies in connection with governmental benefits (including but not limited to, medical, military and social security benefits), and to appoint anyone, including my Agent, to act as my "Represenbenefits and government program including, but not limited to, Social Security and Medicare; to prepare applications, provide information, and perform any other reasonable request by any government orsclaimers under such policies. 8. To receive, deposit, hold, demand, deal with and/or sue to recover all payments I receive from any annuity, pension, retirement benefits, retirement plans, insurance chase, maintain and/or deal with insurance and annuity contracts, insurance policies, including life insurance upon my life or the life of any other appropriate person and to make any elections and dis and to recover possession; and the right to ask for, demand, sue for, collect, recover and receive all monies which may become due and owing to me by reason of such transaction. 7. To apply for, pur execute any necessary document, instrument or deed for such transactions. This includes the right to sell or encumber any homestead that I now own or may own in the future; the right to remove tenantprices my Agent may deem proper) deal with all, any part or any interest in any real or personal property or asset whatsoever, tangible or intangible (now owned or acquired in the future by me) and tohereafter acquire any interest, to have, or use. 6. To maintain, manage, insure, lease, rent, sell, mortgage, improve, repair, exchange, invest, reinvest and in any other manner (on such terms and at , any and all documents of title and demands whatsoever, whether agreed to or disputed, now due or due -1- in the future, owned by, due, owing payable, or belonging to, me or in which I have or may , possess and/or invest any and all sums of money, accounts, debts, bonds, commercial papers, checks, drafts, causes of action, bequests, deposits, notes, interests, dividends, certificates of depositcessary to recover and collect any amount or debt owed to me. 4. To adjust, compromise and settle any claim, against me or asserted on my behalf against any other person or entity. 5. To receive, holdts, security agreements and other debts and obligations and such other instruments in writing of whatever kind and nature as may be. 3. To request, ask, demand, sue and take any and all legal steps neor investments with or through banks, savings and loan, brokers, mutual fund companies or other institutions, proofs of loss, evidences of debts, releases, and satisfaction of mortgages, lien, judgmen, insurance policies, receipts, title documents, checks, drafts, letters of credit, stock certificates, proxies, warrants, commercial papers, withdrawal and deposit slips, certificates of deposit of, t, including but not limited to applications, assignments, bills of sale or lading, bonds, contracts, covenants, conveyances, deeds, options, trust deeds, security agreements, leases, mortgages, notes my behalf and in my name. 2. To enter into binding contracts on my behalf and to sign, endorse and execute any written agreement and document necessary to enter into any such contract and/or agreemeny and the rights hereby granted. My Agent's powers and authority shall include, but not be limited to: 1. To conduct, engage in, and transact any and all lawful business of whatever kind or nature, on I could do if personally present. I hereby ratify and confirm all acts that my Agent, or my Agent's substitute or substitutes, shall lawfully do or cause to be done by virtue of this power of attorneoever that I now have or may later acquire in connection with or relating to any person, item, transaction, thing, business, property, real or personal, tangible or intangible, or matter whatsoever as_____________ my true and lawful attorney-in-fact for me and in my name, and in my behalf. My Agent shall have full power and authority to perform any act, power, duty, legal right or obligation whatsess at _______________________________________________ do hereby make and appoint ________________________________________ ("Agent") maintaining an address at: ________________________________________ponsibilities of an agent. -3- LOUISIANA DURABLE POWER OF ATTORNEY Effective Immediately KNOW ALL PERSONS BY THESE PRESENTS: I, ____________________________________ ("Principal") maintaining an addrealth-care decisions 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 resower of attorney document, 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 hh the power to handle 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 pPAL: The Powers granted by this power of attorney document are broad and sweeping. Before signing this document, consider its consequences. You ("principal") are providing another person ("agent") witl information that is not state specific. Whenever appropriate, the instructions included with the forms packages offered for sale, generally include state specific instructions. -2- CAUTION! PRINCIof Attorney be witnessed, it is always a very good idea to do so. Please note that this information is not intended as and is not a substitute for legal advice. Furthermore, this information is genera challenge the validity of the Power of Attorney and will allow the Durable Power of Attorney to be recorded as a public record, if necessary. Although, some states don't require that a Durable Power rney should always be notarized, even if your state does not require it, especially if the Agent will be dealing with any real property. Notarization will make it more difficult for any third party toaken by the Agent, within the scope of the Power of Attorney document, will be legally binding upon the Grantor. The Grantor can revoke a Durable Power of Attorney at any time. A Durable Power of Attone can be appointed an Attorney-In-Fact by a power of attorney. The Agent should be a competent adult. A Power of Attorney is a "powerful" instrument and should be granted with care. Any action underttor) later becomes incapacitated. Note that the word "attorney" is not used here to mean "lawyer". The person acting as the Attorney-In-Fact for the Principal does not need to be a lawyer. Almost anyoct on his or her behalf, even if the Principal later becomes incapacitated. This particular Form becomes effective immediately and remains in full force and effect even if the Principal (i.e. the Grantive Immediately A Durable Power of Attorney allows a natural "mentally" competent person (called the "Principal" or "Grantor") to authorize someone else (called the "Agent" or "Attorney-InFact") to ag any document with another party. [_] 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 Effect a substitute for legal advice. These forms should only be a starting point for you and should not be used without consulting with an attorney first. An Attorney should be consulted before negotiatin The powers granted by this document are very broad and sweeping, as the Agent has the power to handle business and legal matters on the Principal's behalf. [_] These forms are not intended and are noed. [_] The Principal should be careful in instructing the Agent (or attorney-in-fact) as to the tasks the Agent should complete. The Grantor should also be very careful in the selection of the Agent.gent's spouse or children, and the Notary should not be witnesses. [_] The Principal should keep the original document, as well as a copy. The Agent should have access to the original document as needll allow the Durable Power of Attorney to be recorded as a public record, if necessary. [_] Two witnesses need to sign the Power of Attorney. The witnesses should be competent adults. The Agent, the Aven if the Principal (i.e. the Grantor) becomes subsequently incapacitated. [_] The Principal (i.e. the person granting the power of Attorney) should sign the document before a Notary. Notarization wimation for Durable Power of Attorney Effective Immediately; (3) Durable Power of Attorney Effective Immediately [_] This Durable Power of Attorney becomes effective immediately and remains effective eInstructions & Checklist Louisiana Durable Power of Attorney Effective Immediately [_] This package contains (1) Instructions & Checklist for Durable Power of Attorney Effective Immediately; (2) Infor LouisianaLouisiana -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 __________________________________________ , __________. ______________________________________________________________ Notary Public -5- ___ STATE OF LOUISIANA, COUNTY / PARISH OF _________________________: SWORN TO AND SUBSCRIBED before me, Notary Public in and for the parish / county and state aforesaid, this __________ day of ___________________________ Witness Signature: ___________________________________ Name: ___________________________________ City: __________________________________ State: ________________________________________________ Signature of Principal Witness Signature: ___________________________________ Name: ___________________________________ City: __________________________________ State: ______________of Attorney. I may revoke this Power of Attorney at any time by providing written notice to my Agent. Signed on ________________ (date), at _______________________ (city), Louisiana. ________________ judgment errors made in good faith. However, Agent will be liable for breach of fiduciary duty, failure to act in good faith and/or willful misconduct, while acting under the authority of this Power ration of law, any person relying in good faith on the authority of this document, without notice of such termination, shall be held harmless. -4- Agent shall not be liable for losses resulting fromrevocation. I agree to indemnify the third party for any claims that arise against the third party because of reliance on this power of attorney. If this General Power of Attorney is terminated by opegent. Any third party who receives a copy of this document may act under it. Revocation of the power of attorney is not effective as to a third party until the third party has actual knowledge of the (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 (c) my assets to be subject to a general power of appointment by my A 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 extent necessary to prevent (a) my income to be taxable to my Agent; remain in full force and effect and not be affected by any partial invalidity. No person needs to inquire as to the reasons for the use or issuance of this power-ofattorney or as to the disposition ofpowers granted herein in any manner. If any part of this document is held to be invalid, illegal or unenforceable under applicable law, then the remaining unaffected parts of the document shall still his Power of Attorney shall be construed broadly as a General Power of Attorney. The listing of specific terms, rights, acts or powers are not intended to restrict or limit the definition or scope of t If so requested by myself or any authorized personal representative or fiduciary acting on my behalf, my Agent shall provide an accounting for all funds handled and all acts performed as my Agent. Tnable expenses incurred as a result of carrying out any provision of this Power of Attorney. If desired, my Agent shall also be entitled to reasonable compensation for any services provided as my Agenpacity to receive and evaluate information effectively, to communicate decisions, and/or to manage my financial resources and affairs properly. My Agent shall be entitled to reimbursement of all reaso- authority of this document shall remain in full force and effect thereafter until my death or until my disability or incapacity. As used herein, "disability" or "incapacity" shall mean a lack of car my Agent's estate. This General Power of Attorney and the rights, powers, and authority of my Agent shall become effective immediately upon execution of this instrument. The rights, powers, and -3ust, or other entity, as may be appropriate. However, Agent may not disclaim assets, to which I would be entitled, if the result is that the disclaimed assets pass directly or indirectly to my Agent orust exists at the time of such transfer. 17. To disclaim any interest (subject to other provisions of this document), which might be transferred or distributed to me from any other person, estate, trons of support which my Agent may owe to others, excluding those whom I am legally obligated to support. 16. To transfer any of my assets to the trustee of any revocable trust created by me, if such t favor of my Agent, my Agent's estate, my Agent's creditors, or the creditors of my Agent's estate, or (c) use any of my assets to discharge any of my Agent's legal obligations, including any obligatiy assets, interests or rights, directly or indirectly, to my Agent, my Agent's estate, my Agent's creditors, or the creditors of my Agent's estate, (b) exercise any powers of appointment I may hold inht shall be non-cumulative and shall lapse at the end of each calendar year. However, my Agent may not, unless specifically authorized by this document, (a) gift, appoint, assign or designate any of me shall be limited to gifts that qualify for the federal gift tax annual exclusion, shall not exceed in value the federal gift tax annual exclusion amount in any one calendar year, and this annual rig Gifts to minors may be made to the minor directly or parent, guardian or close friend of the minor or pursuant to the Uniform Gifts to Minors Act or the Uniform Transfers To Minors Act. Any gifts madty, to such persons or organizations without regard to whether such gifts are a part of my estate planning or otherwise, and if necessary, to file any state and federal gift tax returns and documents.agencies, relating to tax matters and to negotiate, compromise or settle any matter with such agency. 15. To make gifts and charitable contributions of my real, personal, tangible or intangible properding, but not limited to, federal, state, local or other income and tax returns and necessary and/or related documents; to obtain or provide information to and from any agency, including governmental nts, investment professionals, brokers and real estate agents. 14. To prepare, or cause to be prepared, sign, and/or file any documents with any federal, state, local or other governmental body, incluhave an interest in or may own or have an interest in, in the future. 13. To employ any professional and/or business assistance as may be appropriate, including but not limited to, attorneys, accountaall rights, including proxy rights, with respect to stocks, bonds, debentures, commodities, options or any other investments. -2- 12. To maintain and/or operate any business that I currently own or rea owned or leased by me alone or in conjunction with any other person, including access to their contents, and to examine, remove, keep or otherwise dispose of the contents. 11. To exercise any and osit, negotiate, sell or transfer any note, security, or draft of the United States of America, including U.S. Treasury Securities. 10. To have access to any safe deposit box, vault or other storage aments, passbooks, drafts, warrants, money orders, certificates, cashier checks, cash or vouchers payable to me by any person, firm, corporation or political entity; to perform any act necessary to depfinancial institution with respect to any of my accounts, including, but not limited to, making deposits and withdrawals, negotiating or endorsing any checks or other instruments, obtaining bank statecounts, certificates of deposit, investment accounts, brokerage accounts, retirement plan accounts, and other similar accounts with financial institutions; to conduct any business with any banking or to act as my "Representative Payee" for the purpose of receiving Social Security benefits. 9. To open, maintain and/or close bank accounts, including, but not limited to, checking accounts, savings act by any government or its agencies in connection with governmental benefits (including but not limited to, medical, military and social security benefits), and to appoint anyone, including my Agent, ment plans, insurance benefits and government program including, but not limited to, Social Security and Medicare; to prepare applications, provide information, and perform any other reasonable requese any elections and disclaimers under such policies. 8. To receive, deposit, hold, demand, deal with and/or sue to recover all payments I receive from any annuity, pension, retirement benefits, retire. 7. To apply for, purchase, maintain and/or deal with insurance and annuity contracts, insurance policies, including life insurance upon my life or the life of any other appropriate person and to makright to remove tenants and to recover possession; and the right to ask for, demand, sue for, collect, recover and receive all monies which may become due and owing to me by reason of such transactione future by me) and to execute any necessary document, instrument or deed for such transactions. This includes the right to sell or encumber any homestead that I now own or may own in the future; the (on such terms and at prices my Agent may deem proper) deal with all, any part or any interest in any real or personal property or asset whatsoever, tangible or intangible (now owned or acquired in thn which I have or may hereafter acquire any interest, to have, or use. 6. To maintain, manage, insure, lease, rent, sell, mortgage, improve, repair, exchange, invest, reinvest and in any other manner ertificates of deposit, any and all documents of title and demands whatsoever, whether agreed to or disputed, now due or due -1- in the future, owned by, due, owing payable, or belonging to, me or iy. 5. To receive, hold, possess and/or invest any and all sums of money, accounts, debts, bonds, commercial papers, checks, drafts, causes of action, bequests, deposits, notes, interests, dividends, cand all legal steps necessary to recover and collect any amount or debt owed to me. 4. To adjust, compromise and settle any claim, against me or asserted on my behalf against any other person or entitrtgages, lien, judgments, security agreements and other debts and obligations and such other instruments in writing of whatever kind and nature as may be. 3. To request, ask, demand, sue and take any icates of deposit of, or investments with or through banks, savings and loan, brokers, mutual fund companies or other institutions, proofs of loss, evidences of debts, releases, and satisfaction of moases, mortgages, notes, insurance policies, receipts, title documents, checks, drafts, letters of credit, stock certificates, proxies, warrants, commercial papers, withdrawal and deposit slips, certifntract and/or agreement, including but not limited to applications, assignments, bills of sale or lading, bonds, contracts, covenants, conveyances, deeds, options, trust deeds, security agreements, lever 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 agreement and document necessary to enter into any such co this power of attorney and the rights hereby granted. My Agent's powers and authority shall include, but not be limited to: 1. To conduct, engage in, and transact any and all lawful business of whater matter whatsoever as I could do if personally present. I hereby ratify and confirm all acts that my Agent, or my Agent's substitute or substitutes, shall lawfully do or cause to be done by virtue ofht or obligation whatsoever that I now have or may later acquire in connection with or relating to any person, item, transaction, thing, business, property, real or personal, tangible or intangible, o___________________________________ my true and lawful attorney-in-fact for me and in my name, and in my behalf. My Agent shall have full power and authority to perform any act, power, duty, legal rig") maintaining an address at _______________________________________________ do hereby make and appoint ________________________________________ ("Agent") maintaining an address at: __________________nt assumes the fiduciary and other legal responsibilities of an agent. -3- LOUISIANA GENERAL POWER OF ATTORNEY KNOW ALL PERSONS BY THESE PRESENTS: I, ____________________________________ ("Principaluthorize anyone to make medical and other health-care decisions 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 agen by your agent, within the scope of this power of attorney document, is legally binding upon you. If you have any questions about these powers, obtain competent legal advice. This document does not a are providing another person ("agent") with the power to handle business and legal matters on your behalf, including the power to sell, mortgage or dispose of your property. Any such action undertakepecific instructions. -2- CAUTION! PRINCIPAL: The Powers granted by this power of attorney document are broad and sweeping. Before signing this document, consider its consequences. You ("principal")ce. Furthermore, this information is general information that is not state specific. Whenever appropriate, the instructions included with the forms packages offered for sale, generally include state sat findlegalforms.com as well), stays in effect even if the Grantor later becomes disabled or incapacitated. Please note that this information is not intended as and is not a substitute for legal adviugh, some states don't require that a General Power of Attorney be witnessed, it is always a very good idea to do so. Another type of Power of Attorney, called a Durable Power of Attorneys (available n will make it more difficult for any third party to challenge the validity of the Power of Attorney and will allow the General Power of Attorney to be recorded as a public record, if necessary. Althower of Attorney at any time. A General Power of Attorney should always be notarized, even if your state does not require it, especially if the Agent will be dealing with any real property. Notarizatiot 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 Grantor. The Grantor can revoke a General Po Principal does not need to be a lawyer. Almost anyone can be appointed an Attorney-In-Fact by a power of attorney. The Agent should be a competent adult. A Power of Attorney is a "powerful" instrumenntil the death of the Grantor or until the Grantor becomes disabled or incapacitated. Note that the word "attorney" is not used here to mean "lawyer". The person acting as the Attorney-In-Fact for thehe "Principal" or "Grantor") to authorize someone else (called the "Agent" or "Attorney-InFact") to act on his or her behalf. This particular Form becomes effective immediately and remains effective us subject to the Disclaimers and Terms of Use found at findlegalforms.com -1- Information General Power of Attorney A General Power of Attorney allows a natural "mentally" competent person (called t for you and should not be used without consulting with an attorney first. An Attorney should be consulted before negotiating any document with another party. [_] The purchase and use of these forms int has the power to handle business and legal matters on the Principal's behalf. [_] These forms are not intended and are not a substitute for legal advice. These forms should only be a starting pointy-in-fact) as to the tasks the Agent should complete. The Grantor should also be very careful in the selection of the Agent. The powers granted by this document are very broad and sweeping, as the Agerincipal should keep the original document, as well as a copy. The Agent should have access to the original document as needed. [_] The Principal should be careful in instructing the Agent (or attorne be dealing with any real estate in Florida. The witnesses should be adults. Generally, anyone related by blood or marriage to the Principal, the Agent or the Notary should not be a witness. [_] The Pcorded as a public record, if necessary. [_] Although not always required, it is always a good idea to also have two witnesses sign the Power of Attorney. Two witnesses are necessary if the Agent will_] The Principal (i.e. the person granting the Power of Attorney; sometimes called the Grantor) should sign the document before a Notary. Notarization will allow the General Power of Attorney to be reeneral Power of Attorney [_] This General Power of Attorney becomes effective immediately and remains effective until the death of the Grantor or until the Grantor becomes disabled or incapacitated. [Instructions & Checklist Louisiana General Power of Attorney [_] This package contains (1) Instructions & Checklist for General Power of Attorney; (2) Information for General Power of Attorney; (3) G LouisianaLouisiana ______________ (Witness Signature) _______________________________________________________ (Witness Signature) ____________________________ 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. _________________________________________ of this declaration and I am emotionally and mentally competent to make this declaration. _______________________________________________________ (Declarant's Signature) ___________________________l 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 refusal. I understand the full importre 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 intention that this declaration shal the dying process, I direct that such procedures be withheld or withdrawn and that I be permitted to die naturally with only the administration of medication or the performance of any medical procedusicians have determined that my death will occur whether or not life-sustaining procedures are utilized and where the application of life- sustaining procedure would serve only to prolong artificiallyith no reasonable chance of recovery, certified to be a terminal and irreversible condition by two physicians who have personally examined me, one of who m shall be my attending physician, and the phytificially prolonged under the circumstances set forth below and do hereby declare: If at any time I should have an incurable injury, disease or illness, or be in a continual profound comatose state w______ day of __________ (month, year). I, __________________________________________________________, being of sound mind, willfully and voluntarily make known my desire that my dying shall not be arsed 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 Declaration made this _________its your particular 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 discusadvice. 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 attorney first to make sure it fe 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 tax the declaration, any physician or health care facility acting in good faith ` rely upon the validity of the declaration. [_] These forms are provided "as is" and no implied or express warranties havtate shall indicate on the declaration Living Will Information & Instructions ­ Page 6 the date and time the notice of revocation was received in his office. Until the notation has been indicated onation 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 in that office. The secretary of snumerated in this Section shall become effective upon communication to the attending physician. (c) The attending physician shall record in the patient's medical records the time and date when notific 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) Such revocation by any method e) (a) By a written revocation of the declarant expressing the intent to revoke, signed and dated by the declarant. (b) The attending physician shall record in the patient's medical record the time andhe following 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. (2g of a copy or facsimile thereof. §1299.58.4. Revocation of declaration A. A declaration may be revoked at any time by the declarant without rega` to his or her mental state or competency by any of t of 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 providinl treatment 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 brace` and a feed authentic. 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 medicaclose 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 deemease "DO 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 disa do- not-resuscitate id entification 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 phr by the person to do so, may register the original, multiple original, or a certified copy of the declaration. Living Will Information & Instructions ­ Page 5 (b) The secretary of state shall issue ondition, as defined in this Part, unless 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 authorizedaining procedures in the event that the declarant is in a continual profound comatose state shall not be invalid for th` reason. Such declaration shall be applicable to any terminal and irreversible chout the invalid direction, and to this end the directions in t` declaration are severable. (3) Any declaration executed prior to January 1, 1992, which does not contain directions regarding life sustications: (form included below) (2) Should 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 witke the treatment decision for the declarant should he be diagnosed as having a terminal and irreversible condition and be comatose, incompetent, or otherwise mentally or physically incapable of communal records. C. (1) The declaration may, but need not, be in the following illustrative form and may include other specific directions including but not limited to a designation of another person to madeclaration is oral or nonverbal, the physician 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 medicregistered shall promptly make the declaration or a copy of the declaration, if written, or a notation of the existence of a registered declaration, a part of the declaran` medical record. (4) If the registry to determine the existence of any such declaration. (3) Any attending physician who is so notified, or who determines directly or is advised by the health care facility that a declaration is ically incapable of communication, any other person may notify the physician of the existence of the declaration. In addition, the attending physician or health care facility may directly contact the shall be the responsibility of the declarant to notify his attending physician that a declaration has been made. (2) In the event the declarant is comatose, incompetent, or otherwise mentally or physeclaration may be made by an adult in the presence of two witnesses by any nonwritten means of communication at any time subsequent to the diagnosis of a terminal and irreversible condition. B. (1) Ital and irreversible condition. (2) A written declaration shall be signed by the declarant in the presence of two witnesses. Living Will Information & Instructions ­ Page 4 (3) An oral or nonverbal dation 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 termin whom life-sustaining procedures are to be withheld or withdrawn upon his decease. 1299.58.3. Making of declaration; notification; illustrative form; registry; issuance of donot-resuscitate identific a competent adult who is not related 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 fromllness which, within reasonable medical judgment, would produce death and for which the application of life-sustaining procedures would serve only to postpone the moment of death. (15) "Witness" meansf state pursuant to this Part. (14) "Terminal and irreversible condition" means a continual profound comatose state with no reasonable chance of recovery or a condition caused by injury, disease, or i two physicians who have personally examined the patient, one of whom shall be the attending physic ian. (13) "Registry" means a registry for declarations established and maintained by the secretary oedical Examiners or by the official licensing authority of another state. (12) "Qualified patient" means a patient diagnosed and certified in writing as having a terminal and irreversible condition by 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 State Board of M condition, including such procedures as the invasive administration of nutrition and hydration and the administration of cardiopulmonary resuscitation. A "life-sustaining procedure" shall not includeedure" 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 and irreversible 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-sustaining procarant" means a person who has executed a declaration as defined herein. Living Will Information & Instructions ­ Page 3 (7) "Do-not-resuscitate identification bracelet" means a standardized braceleting or withdrawal of life-sustaining procedures, in accordance with the requirements of this Part. A declaration may be made in writing, orally, or by other means of nonverbal communication. (6) "Declepartment of Health and Hospitals and who is certified by the bureau. (5) "Declaration" means a witnessed document, statement, or expression voluntarily made by the declarant, authorizing the withholdany person who has successfully completed a training course developed and promulgated by the United States Department of Transportation and adopted by the bureau of emergency medical services of the Devent of a cardiac or respiratory arrest. (3) "Certified emergency medical technician" means a certified emergency medical technician as defined in R.S. 40:1231. (4) "Certified first responder" means an who has primary responsibility for the treatment and care of the patient. (2) "Cardiopulmonary resuscitation" means those measures used to restore or support cardiac or respiratory function in the es. §1299.58.2. Definitions As used in this Part, the following words shall have the meanings ascribed to them unless the context clearly states otherwise: (1) "Attending physician" means the physici` of medically inappropriate treatment or lifesustaining procedures to any patie` or to interfere with medical judgment with respect to the application of medical treatment or life-sustaining procedurlature that nothing in this Part shall be construed to be the exclusive means by which life-sustaining procedures may be withheld or withdrawn, nor shall this Part be construed to require the applicattaining procedures. (2) It is the intent of the legislature that nothing in this Part shall be construed to require the making of a declaration pursuant to this Part. (3) It is the intent of the legisther intends that the making ` a declaration pursuant to this Part merely illustrates a means of documenting a patient's decision relative to withholding or withdrawal of medical treatment or life-susrespect to the application of medical treatment or life-sustaining procedures. B. Intent. (1) The legislature intends that the provisions of this Part are permissive and voluntary. The legislature furo require the application of medically inappropriate treatme` or life-sustaining procedures to any patient or to interfere Living Will Information & Instructions ­ Page 2 with medical judgment with legislature finds and declares that nothing in this Part shall be construed to be the exclusive m` by which life-sustaining procedures may be withheld or withdrawn, nor shall this Part be construed tmunication, or from a minor, in the event such adult patient or minor is diagnosed and certified as having a terminal and irreversible conditions, (4) In furtherance of the rights of such persons, theto make a declaration pursuant to which life-sustaining procedures may be withheld or withdrawn from an adult patient who is comatose, incompetent, or otherwise physically or mentally incapable of comnating another to make the treatment decision and make such a declaration for him, in ` event he is diagnosed as having a terminal and irreversible condition; and (b) The right of certain individuals ares that the laws of the state of Louisiana shall recognize: (a) The right of such a person to make a declaration instructing his physician to withhold or withdraw life-sustaining procedures or desig to the person. (3) In order that the rights of such persons may be respected even after they are no longer able to participate actively in decisions concerning themselves, the legislature hereby decl a terminal and irreversible condition may cause loss of individual and personal dignity and secure only a precarious and burdensome existence while providing nothing medically necessary or beneficialinstances where such persons are diagnosed as having a terminal and irreversible condition. (2) The le gislature further finds that the artificial prolongation of life for a person diagnosed as havingslature finds that all persons have the fundamental right to control the decisions relating to their own medical ca` including the decision to have life-sustaining procedures withheld or withdrawn in For your convenience, we have included useful excerpts from the Louisiana Statutes relating to Living Wills. §1299.58.1. Legislative purpose, findings and intent A. Purpose and findings. (1) The legige contains (1) Information and Instruction for Louisiana Living Will; (2) Louisiana Living Will. This Louisiana Living Will is based on Title 40 Section 1299.58.3 et. Seq. of the Louisiana Statutes. und mind. Witness ______________________________________________________ Witness ______________________________________________________ Information and Instructions Louisiana Living Will This packalaration. Signed ___________________________________________ City, Parish and State of Residence ____________________ The declarant has been personally known to me and I believe him or her to be of soclaration will nevertheless be given effect should the above-discussed circumstance arise. I understand the full import of this declaration and I am emotionally and mentally competent to make this decabove, 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 unwilling to act on my behalf, my demy successor attorney-in- fact, unless the attending physician determines that I have decisional capacity. I have discussed my desires concerning terminal care with my agent and alternate agent named ability 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, unwilling or unavailable to act, by _____________________ (telephone number of successor attorney- in-fact) This power of attorney becomes effective when I can no longer make my own medical decisions, and is not affected by physical dis_______________________________________________ (name of successor attorney- in-fact) _______________________________________________ (address of successor attorney- in- fact) ________________________petent or otherwise mentally or physically incapable of communication. In the event the person I appoint is unable, unwilling or unavailable to act as my attorney- in- fact, I hereby appoint: ________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 irreversible condition and (2) comatose, incom (address of attorney- infact) ______________________________________________________ (telephone number of attorney- in- fact) as my attorney- in- fact to make all medical treatment decisions for me, ______, being of sound mind, willfully and voluntarily appoint: ___________________________________________________ (name of attorney- in-fact) ________________________________________________________f Use found at findlegalforms.com -4- Power of Attorney for Health Care Declaration made this _______________ day of __________ (month, year). I, ____________________________________________________r party. Any -3- possible tax consequences arising out of this document should be discussed with a tax professional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms o using or signing this document you should have an attorney review it to make sure it fits your particular situatio n. You should also consult an attorney whenever a document is negotiated with anothegal and/or tax advice. Laws vary from time to time and from state to state. These forms should only be a starting point for you and should not be used without consulting with an attorney first. Before 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 substitute for leen indicated on the declaration, any physician or health care facility acting in good faith ` rely upon the validity of the declaration. [_] These forms are provided "as is" and no implied or expressa 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 received in his office. Until the notation has bed in the patient's medical records 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 nt to revoke the declaration. (b) Such revocation by any method enumerated in this Section shall become effective upon communication to the attending physician. (c) The attending physician shall recorysician 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 nonverbal expression by the declarant of the interson 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, signed and dated by the declarant. (b) The attending phthout regard to his or her mental state or competency by any of the following methods: (1) By being cancelled, defaced, obliterated, burned, torn, or otherwise destroyed by the declarant or by some pef a declaration, the disclosure of its contents, or the providing of a copy or facsimile thereof. §1299.58.4. Revocation of declaration A. A declaration may be revoked at any time by the declarant wisuing 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 furnishing of information concerning the existence opy thereof prior to the withholding or withdrawal of medical treatment or life-sustaining procedures. (3) The secretary of state may charge a fee of twenty dollars for registering a declaration and ised from the office of the secretary of state shall be deemed authentic. However, nothing herein requires a physician or health care facility to confirm the existence of such declaration or obtain a 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 of the declaration or a facsimile thereof transmittmust include the patient's name, date of birth, and the phrase "DO NOT RESUSCITATE". (2) Any attending physician or health care facility may, orally or in writing, request the secretary of state to co of the declaration. (b) The secretary of state shall issue a do- not-resuscitate identification bracelet to qualified patients listed in the registry. The do- not-resuscitate identification bracelet he 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 the original, multiple original, or a certified copyhall not be invalid for that reason. Such declaration shall be applicable to any terminal and irreversible condition, as defined in this Part, unless it clearly provides to the contrary. D. (1) (a) T3) Any declaration executed prior to January 1, 1992, which does not contain directions regarding life sustaining procedures in the event that the declarant is in a continual profound comatose state s invalid, such invalidity shall not affect other directions of the declaration which can ` given effect without the invalid direction, and to this end the directions in t` declaration are severable. (ersible condition and be comatose, incompetent, or otherwise mentally or physically incapable of communications (see form enclosed below): (2) Should any of the other specific directions be held to beay include other specific directions including but not limited to a designation of another person to make the treatment decision for the declarant should he be diagnosed as having a terminal and irrevhe 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 need not, be in the following illustrative form and m the existence of a registered declaration, a part of the declarant's medical record. -1- (4) If the declaration is oral or nonverbal, the physician shall promptly make a recitation of the reasons ted, 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 written, or a notation ofaration. 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 physician who is so notifien 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 existence of the declion 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 declaration has ben 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 means of communicate, 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) A written declaratioorney for Health Care Form. 1299.58.3. Making of declaration; notification; illustrative form; registry; issuance of donot-resuscitate identification bracelets A. (1) Any adult person may, at any timAttorney 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 Louisiana Statutes relating to the Louisiana Power of Attey for Health Care This package contains (1) Information and Instruction for Louisiana Power of Attorney for Health Care; (2) Louisiana Power of Attorney for Health Care Form. This Louisiana Power of ssed with a 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 Louisiana Power of Attornfits your particular 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 discu 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 attorney first to make sure it e been made or are provided as to their suitability for any specific purpose or as to their legal effect or comp leteness. [_]These forms are not intended and are not a substitute for legal and/or taxce Health 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 havLouisiana Advance Health Care Directive This package contains both a Louisiana Power of Attorney for Health Care and a Louisiana Living Will. Together these forms are also sometimes known as an Advan 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