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Maryland Address -6- owledgment (Notary Public) _________________________________ Name typed, printed, or stamped This Document Prepared by: _____________________________________Name _______________________________________________ (name of Principal), who is personally known to me or who has produced ________________________________ as identification. _________________________________ Signature of person taking ackne of __________________________ ) ) ss County of ________________________ ) -5- The foregoing instrument was acknowledged before me this _____ day of ____________________, ______ by ___________________ State: ___________________________________ BY ACCEPTING OR ACTING UNDER THE APPOINTMENT, THE AGENT ASSUMES THE FIDUCIARY AND OTHER LEGAL RESPONSIBILITIES OF AN AGENT. Notary's Acknowledgment Stat______________________ State: ___________________________________ Witness Signature: ___________________________________ Name: ___________________________________ City: _______________________________e, the Principal appears to be of sound mind and does not appear to be under duress. Witness Signature: ___________________________________ Name: ___________________________________ City: ____________Signature of ("Principal") On this day ______________ (date) I declare that the Principal indicated that he understands the nature of this document and is signing it freely and voluntarily. Furthermor___________ (name of Principal) has executed this Durable Power of Attorney on ____________ (date) at ____________________ (city), __________________________ (state). ________________________________ ful 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. IN WITNESS WHEREOF, _______________d harmless. 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 willttorney. If this Durable -4- 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 hel 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 power of a 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 as to a 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 (c) myr 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 extenthen 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 the use oe 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 law, t 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 powers arreasonable 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 accountingly. 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 entitled to herein, "disability" or "incapacity" shall mean a lack of capacity to receive and evaluate information effectively, to communicate decisions, and/or to manage my financial resources and affairs properfect thereafter until my death. This Power of Attorney shall not terminate on my subsequent disability, incapacity or lack of mental competence (except as provided by any applicable statute). As used the rights, powers, and authority of my Agent shall become effective immediately upon execution of this instrument. The rights, powers, and authority of this document shall remain in full force and efent 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. This Durable Power of Attorney and m 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, as may be appropriate. However, Agse 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 time of such transfer. -3- 17. To disclair 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 my Agent may owe to others, excluding thogent, 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, my Agent's estate, my Agent's creditors, ocalendar year. However, my Agent may not, unless specifically authorized by this document, (a) gift, appoint, assign or designate any of my assets, interests or rights, directly or indirectly, to my Atax 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-cumulative and shall lapse at the end of each 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 gifts that qualify for the federal gift 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 be made to the minor directly or parent, 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 or organizations without regard to whethere and tax returns and necessary and/or related documents; to obtain or provide information to and from any agency, including governmental agencies, relating to tax matters and to negotiate, compromise 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 to, federal, state, local or other incomfuture. 13. To employ any professional and/or business assistance as may be appropriate, including but not limited to, attorneys, accountants, investment professionals, brokers and real estate agents.ks, bonds, debentures, commodities, options or any other investments. 12. To maintain and/or operate any business that I currently own or have an interest in or may own or have an interest in, in the ny 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 proxy rights, with respect to stoc 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 by me alone or in conjunction with a, cashier checks, cash or vouchers payable to me by any person, firm, corporation or political entity; to perform any act necessary to deposit, -2- negotiate, sell or transfer any note, security, oruding, but not limited to, making deposits and withdrawals, negotiating or endorsing any checks or other instruments, obtaining bank statements, passbooks, drafts, warrants, money orders, certificatese accounts, retirement plan accounts, and other similar accounts with financial institutions; to conduct any business with any banking or financial institution with respect to any of my accounts, inclng Social Security benefits. 9. To open, maintain and/or close bank accounts, including, but not limited to, checking accounts, savings accounts, certificates of deposit, investment accounts, brokeragental benefits (including but not limited to, medical, military and social security benefits), and to appoint anyone, including my Agent, to act as my "Representative Payee" for the purpose of receivig, but not limited to, Social Security and Medicare; to prepare applications, provide information, and perform any other reasonable request by any government or its agencies in connection with governmeive, deposit, hold, demand, deal with and/or sue to recover all payments I receive from any annuity, pension, retirement benefits, retirement plans, insurance benefits and government program includince 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 disclaimers under such policies. 8. To recht 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, purchase, maintain and/or deal with insuranent 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 tenants and to recover possession; and the rigth 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 to execute any necessary document, instrum 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 prices my Agent may deem proper) deal wind demands whatsoever, whether agreed to or disputed, now due or due in the future, owned by, due, owing payable, or belonging to, me or in which I have or may hereafter acquire any interest, to have,l sums of money, accounts, debts, bonds, commercial papers, checks, drafts, causes of action, bequests, deposits, notes, interests, dividends, certificates of deposit, any and all documents of title a 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, hold, possess and/or invest any and aland obligations and such other instruments in writing of whatever kind and nature as may be. -1- 3. To request, ask, demand, sue and take any and all legal steps necessary to recover and collect anyvings and loan, brokers, mutual fund companies or other institutions, proofs of loss, evidences of debts, releases, and satisfaction of mortgages, lien, judgments, security agreements and other debts cuments, checks, drafts, letters of credit, stock certificates, proxies, warrants, commercial papers, withdrawal and deposit slips, certificates of deposit of, or investments with or through banks, saions, assignments, bills of sale or lading, bonds, contracts, covenants, conveyances, deeds, options, trust deeds, security agreements, leases, mortgages, notes, insurance policies, receipts, title donto 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 agreement, including but not limited to applicatt'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 my behalf and in my name. 2. To enter ieby 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 attorney and the rights hereby granted. My Agenre in connection with or relating to any person, item, transaction, thing, business, property, real or personal, tangible or intangible, or matter whatsoever as I could do if personally present. I hery-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 whatsoever that I now have or may later acqui______________ do hereby make and appoint ________________________________________ ("Agent") maintaining an address at: _____________________________________________________ my true and lawful attorneHIS POWER OF ATTORNEY IF YOU LATER WISH TO DO SO. KNOW ALL PERSONS BY THESE PRESENTS: I, ____________________________________ ("Principal") maintaining an address at _________________________________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 DECISIONS FOR YOU. YOU MAY REVOKE TRS 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 DOCUMENT, IS LEGALLY BINDING THIS DOCUMENT ARE BROAD AND SWEEPING. BEFORE SIGNING THIS DOCUMENT, CONSIDER ITS CONSEQUENCES. YOU ("GRANTOR") ARE PROVIDING ANOTHER PERSON ("AGENT") WITH THE POWER TO HANDLE BUSINESS AND LEGAL MATTEhe instructions included with the forms packages offered for sale, generally include state specific instructions. -2- DURABLE POWER OF ATTORNEY Effective Immediately (CAUTION): THE POWERS GRANTED BY Please note that this information is not intended as and is not a substitute for legal advice. Furthermore, this information is general information that is not state specific. Whenever appropriate, the Durable Power of Attorney to be recorded 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.ire it, especially if the Agent will be dealing 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 tment, will be legally binding upon the Grantor. The Grantor can revoke a Durable Power of Attorney at any time. A Durable Power of Attorney should always be notarized, even if your state does not requhe Agent should be a competent adult. A Power of Attorney is a "powerful" instrument and should be granted with care. Any action undertaken by the Agent, within the scope of the Power of Attorney docus 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 anyone can be appointed an Attorney-In-Fact by a power of attorney. Tpacitated. This particular Form becomes effective immediately and remains in full force and effect even if the Principal (i.e. the Grantor) later becomes incapacitated. Note that the word "attorney" intally" competent person (called the "Principal" or "Grantor") to authorize someone else (called the "Agent" or "Attorney-InFact") to act on his or her behalf, even if the Principal later becomes incahese forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com -1- Information Durable Power of Attorney Effective Immediately A Durable Power of Attorney allows a natural "mearting point 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 t At the bottom of the document, indicate the name and address of the person who prepared it. [_] These forms are not intended and are not a substitute for legal advice. These forms should only be a sty careful in the selection of the Agent. 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. [_] access to the original document as needed. [_] 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 veresses should be adults. The Agent, the Agent'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 havehe Durable Power of Attorney to be recorded 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. The witn 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 will allow t Durable Power of Attorney Effective Immediately; (3) Durable Power of Attorney Effective Immediately [_] This Durable Power of Attorney becomes effective immediately and remains effective even if theInstructions & Checklist Durable Power of Attorney Effective Immediately [_] This package contains (1) Instructions & Checklist for Durable Power of Attorney Effective Immediately; (2) Information for MarylandMaryland ________________________________ Signature of person taking acknowledgment (Notary Public) _________________________________ Name typed, printed, or stamped -5- his _____ day of ____________________, ______ by __________________________ (name of Principal), who is personally known to me or who has produced ________________________________ as identification. ________________________ State: ___________________________________ State of __________________________ ) ) ss County of ________________________ ) The foregoing instrument was acknowledged before me t_ City: __________________________________ State: ___________________________________ Witness Signature: ___________________________________ Name: ___________________________________ City: _______________ (city), __________________________ (state). ________________________________ Signature of Principal Witness Signature: ___________________________________ Name: __________________________________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 ________________ (date), at ___________________l 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 willful misconduct, while le 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 held harmless. -4- Agent shal 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 power of attorney. If this Durabto 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 as to a third party until the(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 (c) my assets to be subject er-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 extent necessary to prevent fected 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 the use or issuance of this powrict 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 law, then the remaining unaf 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 powers are not intended to restn 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 accounting for all funds handledentitled 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 entitled to reasonable compensatioe and evaluate information effectively, to communicate decisions, and/or to manage my financial resources and affairs properly, as certified in writing by a licensed medical doctor. My Agent shall be 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 a lack of capacity to receivin 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 Attorney shall not terminate rectly 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 disability or incapacity as certified 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 the disclaimed assets pass diust 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 transferred or distributed to me from ions, 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 the trustee of any revocable trof 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 any of my Agent's legal obligatassign 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 estate, (b) exercise any powers ar 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 document, (a) gift, appoint, 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 exclusion amount in any one calendt 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 Act or the Uniform Transfers angible 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 file any state and federal gifncy, including governmental 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, ther 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 information to and from any ageited 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 any federal, state, local or otess 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 appropriate, including but not limcontents. 11. To exercise any and all rights, including proxy rights, with respect to stocks, bonds, debentures, commodities, options or any other investments. 12. To maintain and/or operate any businosit 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 otherwise dispose of the orm 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. To have access to any safe depuments, obtaining bank statements, passbooks, drafts, warrants, money orders, certificates, cashier checks, cash or vouchers payable to me by any person, firm, corporation or political entity; to perfusiness with any banking or financial institution with respect to any of my accounts, including, but not limited to, making deposits and withdrawals, negotiating or endorsing any checks or other instrhecking accounts, savings accounts, certificates of deposit, investment accounts, brokerage accounts, retirement plan accounts, and other similar accounts with financial institutions; to conduct any banyone, 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, including, but not limited to, c any other reasonable request 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 retirement benefits, retirement plans, insurance benefits and government program including, but not limited to, Social Security and Medicare; to prepare applications, provide information, and performppropriate 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 receive from any annuity, pension,y 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 life or the life of any other a 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 become due and owing to me b(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 any homestead that I now own orest 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 whatsoever, tangible or intangible le, 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, repair, exchange, invest, reinvts, 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, owned by, due, owing payabst 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, causes of action, bequests, deposik, 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 or asserted on my behalf againases, and satisfaction of mortgages, 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, asal 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 loss, evidences of debts, releeds, security agreements, leases, mortgages, notes, insurance policies, receipts, title documents, checks, drafts, letters of credit, stock certificates, proxies, warrants, commercial papers, withdrawry to enter into any such contract and/or agreement, including but not limited to applications, assignments, bills of sale or lading, bonds, contracts, covenants, conveyances, deeds, options, trust deall 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 agreement and document necessaause 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, engage in, and transact any and l, 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 substitutes, shall lawfully do or c 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, business, property, real or persona___________________________________ as my alternate or successor Agent, as necessary, to serve with the same powers, rights and discretions. My Agent shall have full power and authority to perform any-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 address at: ____________________________ do hereby make and appoint ________________________________________ ("Agent") maintaining an address at: _____________________________________________________ my true and lawful attorney-inLE POWER OF ATTORNEY Effective upon Disability KNOW ALL PERSONS BY THESE PRESENTS: I, ____________________________________ ("Principal") maintaining an address at _____________________________________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 agent. -3- DURABbinding 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 decisions for you. You may al 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 document, is legally 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 handle business and legic. Whenever appropriate, the instructions included with the forms packages offered for sale, generally include state specific instructions. -2- CAUTION! PRINCIPAL: The Powers granted by this power 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 is not state specifcord, 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 Agent will deal with eal 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 recorded as a public reis 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 dealing with any r 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 the original Agent 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 this Durable Powernt 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 especially important if n 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 "powerful" instrumecipal 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 "lawyer". The perso 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 behalf, even if the Prinase 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 Durable Power of Attorneyhould 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 party. [_] The purchserve 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 advice. These forms susiness 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 serve or continue to he 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 the power to handle bginal 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) as to the tasks t real estate in Florida. The witnesses should be adults. Generally, anyone related by blood or marriage to the Principal, Agent or Notary should not be a witness. [_] The Principal should keep the oriecord, 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 dealing with anyincipal. [_] 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 a public rtion 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 Disability of the PrInstructions & Checklist Durable Power of Attorney Effective upon Disability [_] This package contains (1) Instructions & Checklist for Durable Power of Attorney Effective upon Disability; (2) Informa MarylandMaryland king acknowledgment (Notary Public) _________________________________ Name typed, printed, or stamped -5- ___________________ (name of Principal), who is personally known to me or who has produced ________________________________ as identification. _________________________________ Signature of person ta________ State of __________________________ ) ) ss County of ________________________ ) The foregoing instrument was acknowledged before me this _____ day of ____________________, ______ by _________________________________ Witness Signature: ___________________________________ Name: ___________________________________ City: __________________________________ State: ________________________________________________ Signature of Principal Witness Signature: ___________________________________ Name: ___________________________________ City: __________________________________ State: _________evoke this Power of Attorney at any time by providing written notice to my Agent. Signed on ________________ (date), at _______________________ (city), __________________________ (state). ___________e 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 of Attorney. I may rerson 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 from judgment errors madto 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 operation of law, any py 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 revocation. I agree 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 Agent. Any third parto 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; (b) my Agent to have 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 of any proceeds paid tn 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 remain in full forcey 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 powers granted herei 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. This Power of Attornered 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 Agent If so requested byd 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 reasonable expenses incur 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 capacity to receive an 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 -3- authority of this, 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 or my Agent's estate.ime 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 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 trust exists at the tmy 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 whichor 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, lative 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 o 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 right shall be non-cumu 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 made shall be limited tor 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 mayo 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 property, to such persons d 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 agencies, relating tessionals, 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 limiteor 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 profg 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 have an interest in 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 all rights, includinl 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 afts, 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, seln 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, dr of deposit, investment accounts, brokerage accounts, retirement plan accounts, and other similar accounts with financial institutions; to conduct any business with any banking or financial institutioentative 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, certificatesor 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 "Represe benefits 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 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, retirement plans, insurancurchase, 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 nts 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, pto 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 tenat 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 the future by me) and y 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 (on such terms and ait, 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 mald, 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 deposnecessary 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, hoents, 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 , 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 mortgages, lien, judgmes, insurance policies, receipts, title documents, checks, drafts, letters of credit, stock certificates, proxies, warrants, commercial papers, withdrawal and deposit slips, certificates of deposit ofent, including but not limited to applications, assignments, bills of sale or lading, bonds, contracts, covenants, conveyances, deeds, options, trust deeds, security agreements, leases, mortgages, noton 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 agreemney 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, 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 of this power of attortsoever 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 _______________ 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 whadress at _______________________________________________ do hereby make and appoint ________________________________________ ("Agent") maintaining an address at: ______________________________________ the fiduciary and other legal responsibilities of an agent. -3- GENERAL POWER OF ATTORNEY KNOW ALL PERSONS BY THESE PRESENTS: I, ____________________________________ ("Principal") maintaining an adnyone 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 agent assumesagent, 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 authorize ading 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 undertaken by your structions. -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") are provirmore, 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 specific inalforms.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 advice. Furthestates 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 at findlege 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. Although, some orney 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. Notarization will makld 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 Power of Att 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" instrument and shoueath 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 the Principalpal" 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 until the dto 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 the "Princind 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 is subject 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 point for you a 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 dealinncipal (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 recorded as er 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. [_] The PriInstructions & Checklist General Power of Attorney [_] This package contains (1) Instructions & Checklist for General Power of Attorney; (2) Information for General Power of Attorney; (3) General Pow MarylandMaryland ication. _________________________________ Signature of person taking acknowledgment (Notary Public) _________________________________ Name typed, printed, or stamped -4- efore me this _____ day of ____________________, ______ by __________________________ (name of Principal), who is personally known to me or who has produced ________________________________ as identific) _________________________________ Name typed, printed, or stamped -3- State of __________________________ ) ) ss County of ________________________ ) The foregoing instrument was acknowledged bncipal), who is personally known to me or who has produced ________________________________ as identification. _________________________________ Signature of person taking acknowledgment (Notary Publ_____________ ) ) ss County of ________________________ ) The foregoing instrument was acknowledged before me this _____ day of ____________________, ______ by __________________________ (name of Priess Signature: ___________________________________ Name: ___________________________________ City: __________________________________ State: ___________________________________ State of _____________re of Mother Witness Signature: ___________________________________ Name: ___________________________________ City: __________________________________ State: ___________________________________ Witn Signed on ________________ (date), at _______________________ (city), __________________________ (state). ________________________________ Signature of Father ________________________________ Signatument, without notice of such termination, shall be held harmless. -2- We may revoke this Power of Attorney before the expiration date at any time by providing written notice to the Attorney-in-Fact.arise against the third party because of reliance on this power of attorney. If this Power of Attorney is terminated by operation of law, any person relying in good faith on the authority of this docuer it. Revocation of the power of attorney is not effective as to a third party until the third party has actual knowledge of the revocation. We agree to indemnify the third party for any claims that e remaining unaffected parts of the document shall still remain in full force and effect and not be affected by any partial invalidity. Any third party who receives a copy of this document may act undonable expenses incurred as a result of carrying out any provision of this Power of Attorney. If any part of this document is held to be invalid, illegal or unenforceable under applicable law, then the hereby ratify and confirm all acts by the Attorney-in-Fact done by virtue of this power of attorney and the rights hereby granted. The Attorney-in-Fact shall be entitled to reimbursement of all reasation date"). By signing here, we indicate that we are fully informed as to the contents of this document and understand the full import of this grant of powers to the Attorney-in-Fact named herein. W to the marriage of our child/children; (iii) have the power to consent to the adoption of our child/children. This power of attorney shall be in effect from _______________ to _______________ ("expir other provisions in this Power of Attorney, Attorney-in-Fact shall not (i) have the authority to withhold or withdraw life sustaining procedures for any child/children; (ii) have the power to consentrformance of the powers granted by this document, including but not limited to consent forms, releases, waivers, insurance documents, claims, agreements, contracts and legal documents. Notwithstandingnsurance for our child/children and to make and file any medical or other type of claim against any health or other type of insurance company. 6. Endorse and execute any documents necessary for the pe child/children and to adjust, compromise and settle any claim, our child/children may have against any other person or entity. 5. Apply for, purchase, maintain and/or deal with any health and other inot limited to, provisions of living quarters, food, clothing, entertainment and other customary matters. -1- 4. Request, ask, demand, sue and take any and all legal steps necessary on behalf of our our child/children to participate in activities and events offered by any group, organization or educational facility. 3. Maintain the customary living standard of the child/children, including, but ducation of our child/children and to register and enroll our child/children in any educational programs, schools and extracurricular activities; review any school records of the child/children; allow our child/children. Health care shall include but not be limited to the administration of anesthesia, X-ray examination, performance of operations, diagnostic and other procedures. 2. Determine the ents of any medical records; execute any consent, release or waiver of liability required by medical, dental or other health authorities incident to the provision of medical, surgical or dental care tohealth care at any hospital or other institution; employ any physicians, dentists, nurses, or other person whose services may be needed for such health care; review and if necessary disclose the conteary or desirable for maintaining the health, education, and welfare of our above named child/children, including, but not limited to, the powers to: 1. Provide for, approve, authorize and decline any on __________ Name: _________________________________ born on __________ The above named Attorney-in-Fact shall have the power and authority to act entirely in loco parentis and to do all acts necess__________________ born on __________ Name: _________________________________ born on __________ Name: _________________________________ born on __________ Name: _________________________________ borngent and attorney-in-fact for us and in our name, and in our behalf to act as the guardian of our minor child/children: Name: _________________________________ born on __________ Name: _______________________ hereby make and appoint ________________________________________ ("Attorney-in-Fact") maintaining an address at: _____________________________________________________ as our true and lawful a________________________ ("Father") and ______________________________________ ("Mother"), jointly referred to as "Parents" or "Principals", maintaining an address at: ________________________________orney-in-Fact assumes the fiduciary and other legal responsibilities of an agent. -3- POWER OF ATTORNEY FOR THE CARE OF CHILDREN KNOW ALL PERSONS BY THESE PRESENTS: We ______________________________If you have any questions about these powers, obtain competent legal advice. You may revoke this power of attorney at any time. ATTORNEY-IN-FACT: By accepting or acting under the appointment, the Attrol the care, custody, health and welfare of your child/children. Any such action undertaken by the Attorney-in-Fact, within the scope of this power of attorney document, is legally binding upon you. f Children document are broad and sweeping. Before signing this document, consider its consequences. You ("Parents") are providing another person ("Attorney-in-Fact") with the power to handle and cont, the instructions included with the forms packages offered for sale, generally include state specific instructions. -2- CAUTION! PARENTS: The powers granted by this Power of Attorney for the Care oso. Please note that this information is not intended as and is not a substitute for legal advice. Furthermore, this information is general information that is not state specific. Whenever appropriatet more difficult for any third party to challenge the validity of the Power of Attorney. Although, some states don't require that a Power of Attorney be witnessed, it is always a very good idea to do ke the document at any time even before the expiration date. The Power of Attorney for the Care of Children should always be notarized, even if your state does not require it. Notarization will make in instructing the Attorney-in-Fact as to what the Attorney-in-Fact should do. Although the Power of Attorney for the Care of Children has a beginning and an "end/expiration" date, the Parents can revoselection of the Attorney-in-Fact, as the powers granted by this document are very broad and sweeping and the children are being entrusted to the Attorney-in-Fact. The Parents should also be careful ior any other type of care. Medical personnel will also generally feel more comfortable dealing with an Attorney-inFact who can provide this type of document. The Parents should be very careful in the cument available, the Attorney-in-Fact will be able to better deal with any types of emergency involving the children and can avoid potential problems when, for example, arranging for medical, dental l be absent for a period of time. The powers granted by this instrument are very broad. Parents are basically giving temporary custody of the children to the Attorney-infact. By having this type of doattorney. This form allows the Attorney-in-Fact to make decisions for the children in place of the parents, including health care, education and welfare decisions. This can be useful if the parent wilot used here to mean "lawyer". The person acting as the Attorney-in-Fact for the Parents or the children does not need to be a lawyer. Almost anyone can be appointed an Attorney-in-Fact by a power of allows parents of one or more children (sometimes called the "Principals" or "Grantors") to appoint another person to act as their Attorney-in-Fact to care for their children. The word "attorney" is nney for the Care of Children Whenever it becomes necessary to allow someone else to provide for the care of your children, a Power of Attorney for the Care of Children form can be used. This document 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 -1- Information Power of Attorers granted by this document are very broad and sweeping. [_] These forms are not intended and are not a substitute for legal advice. These forms should only be a starting point for you and should notary should not be a witness. [_] The Parents should be careful giving instructions to the Attorney-in-Fact. The Parents should also be very careful in the selection of the Attorney-in-Fact, as the pow, it is always a good idea to also have two witnesses sign the Power of Attorney. The witnesses should be adults. Generally, anyone related by blood or marriage to the Parents, Attorney-in-Fact or Notp a copy of the Power of Attorney for the Care of Children document for their records. [_] At least one witness should sign the Power of Attorney for the Care of Children. Although not always required of Attorney for the Care of Children document before a Notary. [_] The original Power of Attorney for the Care of Children document should be given to the Attorney-in-Fact. [_] The Parents should keeional useful information about Power of Attorney for the Care of Children documents. [_] Both Parents need to sign the Power of Attorney for the Care of Children. [_] The Parents should sign the PowerInstructions & Checklist Power of Attorney for the Care of Children [_] This package contains a (1) Power of Attorney for the Care of Children; (2) simple instructions plus a checklist; and (3) addit MarylandMaryland : ___________________________________ Address: ______________________________________ Phone: _______________________________________ Date: ________________ -6- ___ Address: ______________________________________ Phone: _______________________________________ Date: ________________ _____________________________________________ (Witness Signature) Print Namein my presence and based upon personal observation appears to be a competent individual. _____________________________________________ (Witness Signature) Print Name: ________________________________larant) (At least one of your witnesses may not be a person who may financially benefit by reason of Declarant's death). The declarant signed or acknowledged signing the foregoing advance directive y competent to make this advance directive and that I understand the purpose and effect of this document. ______________________ (Date) ____________________________________________ (Signature of Dec_____________________________________________________ _____________________________________________________________________________ -5- By signing below, I indicate that I am emotionally and mentalllowing space, indicate any other instructions regarding receipt or nonreceipt of any health care) _____________________________________________________________________________ ________________________d that my estate will not be charged for any costs associated with my decision to donate my organs, tissues, or eyes or the actual disposition of my organs, tissues, or eyes. (8) I direct (in the folth, I direct that all support measures be continued to maintain the viability for transplantation of my organs, tissues, and eyes until organ, tissue, and eye recovery has been completed. I understan_____ For medical education _____ For any purpose authorized by law. I understand that before any vital organ, tissue, or eye may be removed for transplantation, I must be pronounced dead. After dear eyes: _______________ ________________________________________________________ I authorize the use of my organs, tissues, or eyes: _____ For transplantation _____ For therapy _____ For research ____________________________________________________________________ -4- (7) Upon my death, I wish to donate: _____ Any needed organs, tissues, or eyes. _____ Only the following organs, tissues, oures shall be modified as follows: _____________________________________________________________________________ _____________________________________________________________________________ _________ect that no matter what my condition, I be given all available medical treatment in accordance with accepted health care standards. (6) If I am pregnant, my decision concerning life-sustaining procedive nutrition and hydration artificially. (4) I direct that no matter what my condition, medication not be given to me to relieve pain and suffering, if it would shorten my remaining life. (5) I dirdministration of nutrition and hydration artificially. __________ I direct that my life not be extended by life-sustaining procedures, except that if I am unable to take food by mouth, I wish to recee degree of medical certainty, treatment of the irreversible condition would be medically ineffective - __________ I direct that my life not be extended by life-sustaining procedures, including the a caused by injury, disease, or illness, as a result of which I have suffered severe and permanent deterioration indicated by incompetency and complete physical dependency and for which, to a reasonablnded by life-sustaining procedures, except that if I am unable to take food by mouth, I wish to receive nutrition and hydration artificially. (3) If I have an end-stage condition, that is a conditiony - __________ I direct that my life not be extended by life-sustaining procedures, including the administration of nutrition and hydration artificially. __________ I direct that my life not be exte- (2) If I am in a persistent vegetative state, that is, if I am not conscious and am not aware of my environment or able to interact with others, and there is no reasonable expectation of my recoverficially. __________ I direct that my life not be extended by life-sustaining procedures, except that if I am unable to take food by mouth, I wish to receive nutrition and hydration artificially. -3e used there is no reasonable expectation of my recovery - __________ I direct that my life not be extended by life-sustaining procedures, including the administration of nutrition and hydration artit my health care providers to follow my instructions as set forth below. (Initial all those that apply.) (1) If my death from a terminal condition is imminent and even if life-sustaining procedures artial those statements you want to be included in the document and cross through those statements that do not apply.) If I am incapable of making an informed decision regarding my health care, I direcrt B Advance Medical Directive Health Care Instructions (Optional Form) (Cross through if you do not want to complete this portion of the form. If you do want to complete this portion of the form, ini_________ (Witness Signature) Print Name: ___________________________________ Address: ______________________________________ Phone: _______________________________________ Date: ________________ Pant Name: ___________________________________ Address: ______________________________________ Phone: _______________________________________ Date: ________________ ____________________________________his appointment of a health care agent in my presence and based upon my personal observation appears to be a competent individual. _____________________________________________ (Witness Signature) Priand that I understand its purpose and effect. ______________________ (Date) ____________________________________________ (Signature of Declarant) -2- The declarant signed or acknowledged signing thall not be liable for the costs of care based solely on this authorization. By signing below, I indicate that I am emotionally and mentally competent to make this appointment of a health care agent nsidering the benefits, burdens, and risks that might result from a given treatment or course of treatment, or from the withholding or withdrawal of a treatment or course of treatment. (6) My agent s wishes as otherwise known to my agent. If my wishes are unknown or unclear, my agent is to make health care decisions for me in accordance with my best interest, to be determined by my agent after coon regarding my health care; or ___________ When this document is signed. (5) My agent is to make health care decisions for me based on the health care instructions I give in this document and on my(4) My agent's authority becomes operative (initial the option that applies): ___________ When my attending physician and a second physician determine that I am incapable of making an informed decisi__________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ ng, in appropriate circumstances, life-sustaining procedures. (3) The authority of my agent is subject to the following provisions and limitations (or write none): ___________________________________transfer to another facility) any hospital, hospice, nursing home, adult home, or other medical care facility; and -1- d. Consent to the provision, withholding, or withdrawal of health care, includiot limited to, medical and hospital records, and consent to disclosure of this information; b. Employ and discharge my health care providers; c. Authorize my admission to or discharge from (including r and authority to make health care decisions for me, including the power to: a. Request, receive, and review any information, oral or written, regarding my physical or mental health, including, but n____________________________________________________ _____________________________________________________________________________ (Full Name, Address, and Telephone Number) (2) My agent has full powedress, and Telephone Number) Optional: If this agent is unavailable or is unable or unwilling to act as my agent, then I appoint the following person to act in this capacity _________________________health care decisions for me: _____________________________________________________________________________ _____________________________________________________________________________ (Full Name, Ad_______________________________________________________, residing at _____________________________________________________________________________ appoint the following individual as my agent to make an agent, cross through any items in the form that you do not want to apply. If you decide to select a health care agent that person may not be a witness to your advance directive.) (1) I, _________ Advance Directive Part A Appointment of Health Care Agent (optional) (Cross through if you do not want to appoint a health care agent to make health care decisions for you. If you do want to appointences arising out of this document should be discussed with a tax professional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com. -6-hout consulting an attorney first to make sure it fits your particular situation. Advice from a local attorney is always recommended when dealing with estate planning matters. Any possible tax consequnded and are not a substitute for legal and/or tax advice. Laws vary from time to time and from state to state. These forms should only be a starting point for you and should not be used or signed wited "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 are not inteord. (c) It shall be the responsibility of the declarant, to the extent reasonably possible, to notify any person to whom the declarant has provided a copy of the directive. [_] These forms are provide directive by an oral statement to a health care practitioner, the practitioner and a witness to the oral revocation shall document the substance of the oral revocation in the declarant's medical recigned and dated writing, by physical cancellation or destruction, by an oral statement to a health care practitioner or by the execution of a subsequent directive. (b) If a declarant revokes an advancservices provided to the declarant. A statement of medications preferred by the declarant for psychiatric treatment; § 5-604. (a) An advance directive may be revoked at any time by a declarant by a st the declarant would prefer to provide mental health services; (3) and (4) Instruction regarding the notification of third parties and the release of information to third parties about mental health services may include: (1) declarant; The designation of an agent to make mental health services decisions for the (2) The identification of mental health professionals, programs, and facilities tha under § 5-604 of this subtitle for the revocation of an advance directive shall apply to the revocation of an advance directive for mental health services. (d) An advance directive for mental health ) An individual making an advance directive for mental health services shall follow the procedures for making an advance directive provided under § 5-602 of this subtitle. (2) The procedur es providedhealth services which may be provided to the individual if the individual becomes incompetent and has a need for mental health services either during, or as a result of, the incompetency. -5- (c) (1 5-602.1. (a) In this section, "mental health services" has the meaning stated in § 4-301(i)(1) of this article. (b) An individual who is competent may make an advance directive to outline the mental nce with the provisions of § 5-605(c) of this subtitle. (i) The absence of an advance directive creates no presumption as to the patient's intent to consent to or refuse life-sustaining procedures. §e agent that the agent has been named in an advance directive to act on the declarant's behalf. (h) Unless otherwise provided in the patient's advance directive, a patient's agent shall act in accordag the date the advance directive was made and the name of the attending physician, a part of the declarant's medical records. (g) It shall be the responsibility of the declarant to notify a health carake the advance directive or a copy of the advance directive a part of the declarant's medical records; or (ii) If the advance directive is oral, make the substance of the advance directive, includ in the physician of the existence of an advance directive. (2) An attending physician who is notified of the existence of the advance directive shall promptly: (i) If the advance directive is written, mo notify the attending physician that an advance directive has been made. In the event the declarant becomes comatose, incompetent, or otherwise incapable of communication, any other person may notifyscious, or unable to communicate by any means, the certification of a second physician is not required under paragraph (1) of this subsection. (f) (1) It shall be the responsibility of the declarant tective shall become effective when the declarant's attending physician and a second physician certify in writing that the patient is incapable of making an informed decision. (2) If a patient is unconed as part of the individual's medical record. The documentation shall be dated and signed by the attending physician and the witness. (e) (1) Unless otherwise provided in the document, an advance dirce directive shall have the same effect as a written advance directive if made in the presence of the attending physician and one witness and if the substance of the oral advance directive is documentance directive to authorize the providing, withholding, or withdrawing of any life-sustaining procedure or to appoint an agent to make health care decisions for the individual. -4- (2) An oral advangly entitled to any portion of the estate of the declarant or knowingly entitled to any financial benefit by reason of the death of the declarant. (d) (1) Any competent individual may make an oral advn caring for the declarant if acting in good faith. (ii) The health care agent of the declarant may not serve as a witness. (iii) At least one of the witnesses must be an individual who is not knowin) (i) Except as provided in items (ii) and (iii) of this paragraph, any competent individual may serve as a witness to an advance directive, including an employee of a health care facility or physicia subtitle to make health care decisions for a declarant. (c) (1) A written advance directive shall be dated, signed by or at the express direction of the declarant, and subscribed by two witnesses. (2ld qualify as a surrogate decision maker under § 5-605(a) of this subtitle. (3) An agent appointed under this subtitle has decision making priority over any individuals otherwise authorized under thisted in the advance directive. (2) An owner, operator, or employee of a health care facility from which the declarant is receiving health care may not serve as a health care agent unless the person wouom that individual. (b) (1) Any competent individual may, at any time, make a written advance directive appointing an agent to make health care decisions for the individual under the circumstances sta § 5-602. (a) Any competent individual may, at any time, make a written advance directive regarding the provision of health care to that individual, or the withholding or withdrawal of health care frby injury, disease, or illness which, to a reasonable degree of medical certainty, makes death imminent and from which, despite the application of life-sustaining procedures, there can be no recovery.ician" means a person licensed to practice medicine in the State or in the jurisdiction where the treatment is to be rendered or withheld. (q) "Terminal condition" means an incurable condition caused onse; and -3- (2) From which, after the passage of a medically appropriate period of time, it can be determined, to a reasonable degree of medical certainty, that there can be no recovery. (p) "Physs of consciousness, exhibiting no behavioral evidence of self-awareness or awareness of surroundings in a learned manner other than reflex activity of muscles and nerves for low level conditioned resplth of an individual; or Prevent the impending death of an individual. "Persistent vegetative state" means a condition caused by injury, disease, or illness: (1) In which a patient has suffered a losy resuscitation. (n) "Medically ineffective treatment" means that, to a reasonable degree of medical certainty, a medical procedure will not: (1) (2) (o) Prevent or reduce the deterioration of the hea recovery from a terminal condition, persistent vegetative state, or end-stage condition. (2) "Life-sustaining procedure" includes artificially administered hydration and nutrition, and cardiopulmonar that: (i) Utilizes mechanical or other artificial means to sustain, restore, or supplant a spontaneous vital function; and (ii) Is of such a nature as to afford a patient no reasonable expectation ofle to communicate by means other than speech may not be considered incapable of making an informed decision. (m) (1) "Life-sustaining procedure" means any medical procedure, treatment, or intervention evaluation of the burdens, risks, and benefits of the treatment or course of treatment, or is unable to communicate a decision. (2) For the purposes of this subtitle, a competent individual who is abtreatment or course of treatment because the patient is unable to understand the nature, extent, or probable consequences of the proposed treatment or course of treatment, is unable to make a rationalividuals. (l) (1) "Incapable of making an informed decision" means the inability of an adult patient to make an informed decision about the provision, withholding, or withdrawal of a specific medical ractitioner or a facility that provides health care to individuals. (2) "Health care provider" includes agents or employees of a health care practitioner or a facility that provides health care to indicle to provide health care; or (2) The administrator of a hospital or a person designated by the administrator in accordance with hospital policy. (k) (1) "Health care provider" means a health care psible condition would be medically ineffective. (j) "Health care practitioner" means: -2- (1) An individual licensed or certified under the Health Occupations Article or § 13516 of the Education Art That has caused severe and permanent deterioration indicated by incompetency and complete physical dependency; and (2) For which, to a reasonable degree of medical certainty, treatment of the irreverl ventilation, defibrillation, and other related life-sustaining procedures. (i) "End-stage condition" means an advanced, progressive, irreversible condition caused by injury, disease, or illness: (1)mergency medical services personnel to withhold or withdraw cardiopulmonary resuscitation including cardiac compression, endotracheal intubation, other advanced airway management techniques, artificiay Medical Services in conjunction with the State Board of Physician Quality Assurance which, in the event of a cardiac or respiratory arrest of a particular patient, authorizes certified or licensed eting an informed decision. (h) "Emergency medical services `do not resuscitate order'" means a physician's written order in a form established by protocol issued by the Maryland Institute for Emergencatment and who has not been determined to be incapable of making an informed decision. (g) "Declarant" means a competent individual who makes an advance directive while capable of making and communicaetermining best interest. (f) "Competent individual" means a person who is at least 18 years of age or who under § 20-102(a) of this article has the same capacity as an adult to consent to medical trereatment or the withholding or withdrawal of the treatment; and (7) The religious beliefs and basic values of the individual receiving treatment, to the extent these may assist the decision maker in d The effect of the treatment on the life expectancy of the individual; The prognosis of the individual for recovery, with and without the treatment; (6) The risks, side effects, and benefits of the tding or withdrawal of treatment result in a severe and continuing impairment of the dignity of the individual by subjecting the individual to a condition of extreme humiliation and dependency; (4) (5)in or discomfort caused to the individual by the treatment, or the withholding or withdrawal of the treatment; (3) The degree to which the individual's medical condition, the treatment, or the withholndividual resulting from that treatment, taking into account: (1) The effect of the treatment on the physical, emotional, and cognitive functions of the individual; -1- (2) The degree of physical paysician who has primary responsibility for the treatment and care of the patient. (e) "Best interest" means that the benefits to the individual resulting from a treatment outweigh the burdens to the ilt appointed by the declarant under an advance directive made in accordance with the provisions of this subtitle to make health care decisions for the declarant. (d) "Attending physician" means the phhe declarant in accordance with the requirements of this subtitle; or (2) A witnessed oral statement, made by the declarant in accordance with the provisions of this subtitle. (c) "Agent" means an adu Advance Medical Directive. § 5-601. (a) In this subtitle the fo llowing words have the meanings indicated. (b) "Advance directive" means: (1) A witnessed written document, voluntarily executed by tical Directive is based on the following Maryland Statutes: "Health General § 5-601 et. Seq." For your convenience, we have included useful relevant excerpts from the Maryland Statutes relating to the The health care agent may not be a witness to your advance directive. At least one of your witnesses may not be a person who may financially benefit by reason of your death. This Maryland Advance Medion and Instruction for Maryland Advance Medical Directive (Power of Attorney for Health Care & Living Will); (2) Maryland Advance Medical Directive (Power of Attorne y for Health Care & Living Will).he event of terminal condition, persistent vegetative state, or end-stage condition. You can also use the adva nce directive to make any other health care decisions. This package contains (1) Informat health care issues, by allowing you to select a health care agent, give health care instructions, or both. By using the Advance Directive, you can make decisions about life-sustaining procedures in tInformation and Instructions Maryland Advance Medical Directive (Power of Attorney for Health Care & Living Will) The Maryland Advance Medical Directive, allows you to make some decisions about future Maryland