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Maryland ________________________________ 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 of which the person(s) acted, executed the instrument. WITNESS my hand and official seal. Signature __________________________________ (Seal) t and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf________________________________ ___________, personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrumen__________ before me, (here insert name and title of the officer), personally appeared ________________________________________________________________________ ________________________________________________ Names of institutions/individuals who have been provided a copy of this revocation: Notary Acknowledgment State of __________________________ County of ________________________ ) ) ss ) On ______ State:_________________________ Witness Signature:__________________ Date: ___________________________ Name: ___________________________ City: _________________________ State:_________________ ___________________ (date). _____________________________ Principal Witness Signature:__________________ Date: ___________________________ Name: ___________________________ City: ___________________ artificial life sustaining procedures is revoked and withdrawn and this document provides notice of such revocation. IN WITNESS WHEREOF, I have signed this Health Care Power of Attorney Revocation on______________________________ (title of document(s)) dated __________________ and all power and authority granted thereby including powers for making health care decisions on my behalf and concerningRevocation I, ___________________________________ (Principal) maintaining an address at __________________________________________________ (address of Principal), hereby revoke my ____________________ion that is not state specific. Whenever appropriate, the instructions included with the forms packages offered for sale, generally include state specific instructions. Health Care Power of Attorney revoked. This revocation becomes effective immediately. Please note that this information is not intended as and is not a substitute for legal advice. Furthermore, this information is general informate Power of Attorney Revocation is used by the Grantor to give notice that a previously granted Health Care Power of Attorney (sometimes referred to as a Living Will or Health Care Directive) has been alth Care Power of Attorney Revocation If the Grantor of a Health Care Power of Attorney decides to revoke the document, it is almost always required that the revocation be in writing. The Health Carfor you and should not be used without consulting with an attorney first. The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Information Hetify both. These forms are not intended and are not a substitute for legal advice. Laws are different from state to state and may change from time to time. These forms should only be a starting point e revocation document. If more than one document is being revoked, then each document needs to be identified i.e. if you are revoking a Health Care Power of Attorney and a Living Will, be sure to idenpies of the Health Care Power of Attorney so as to avoid any questions about the revocation or its effectiveness. The exact full title of the document(s) that you are revoking should be inserted in thon. In the event the original power of attorney was filed publicly (i.e. recorded), then the notice of revocation should also be filed publicly, in the same manner. The Principal should destroy any coceived a copy of the original Power of Attorney or who may have dealt with the Agent acting on behalf of the Principal. It is a good idea to keep a record of anyone who was sent a copy of the revocatio the Principal, the Agent or the Notary should not be a witness. The Principal should keep a copy of the revocation in his/her files. Copies of the revocation should be sent to anyone who may have reough not always required, it is always a good idea to also have two witnesses sign the Revocation of Power of Attorney. The witnesses should be adults. Generally, anyone related by blood or marriage tified mail receipt, delivery receipt etc..). Any health care providers need to be given a copy of the Revocation as well and copies of the revocation should be kept in any relevant medical files. Alth show that it was the Grantor's intent to revoke the Power of Attorney. If possible, the Principal should keep a copy of any document showing that the Agent received the original revocation (i.e. certd. Notarization is also necessary to record the revocation. This revocation becomes effective immediately. The original or a copy of the revocation must be given to the Agent (i.e. Attorney-inFact) tohe Health Care Power of Attorney Revocation before a Notary even if it is not required. Notarization will also help to ensure that the revocation is effective and support its authenticity if challengeer of Attorney Revocation (3) Health Care Power of Attorney Revocation The Principal (i.e. the person granting the Health Care Power of Attorney Revocation; sometimes called the Grantor) should sign tInstructions & Checklist Health Care Power of Attorney Revocation This package includes (1) Checklist & Instructions for Health Care Power of Attorney Revocation (2) Information about Health Care Pow MarylandMaryland __ 3 _______________ (Witness Signature) Print Name: ___________________________________ Address: ______________________________________ Phone: _______________________________________ Date: ______________e) Print Name: ___________________________________ Address: ______________________________________ Phone: _______________________________________ Date: ________________ ______________________________edged signing this living will in my presence and based upon my personal observation the declarant appears to be a competent individual. _____________________________________________ (Witness Signaturmake this living will and that I understand its purpose and effect. ______________________ (Date) ____________________________________________ (Signature of Declarant) The declarant signed or acknowliated with my decision to donate my organs, tissues, or eyes or the actual disposition of my organs, tissues, or eyes. 2 By signing below, I indicate that I am emotionally and mentally competent to maintain the viability for transplantation of my organs, tissues, and eyes until organ, tissue, and eye recovery has been completed. I understand that my estate will not be charged for any costs assochorized by law. I understand that before any vital organ, tissue, or eye may be removed for transplantation, I must be pronounced dead. After death, I direct that all support measures be continued to _______________________________ I authorize the use of my organs, tissues, or eyes: _____ For transplantation _____ For therapy _____ For research _____ For medical education _____ For any purpose aut____________________________ d. Upon my death, I wish to donate: _____ Any needed organs, tissues, or eyes. _____ Only the following organs, tissues, or eyes: _______________ _________________________uctions: ______________________________________________________ ______________________________________________________ ______________________________________________________ __________________________ation artificially. _____ I direct that I be given all available medical treatment in accordance with accepted health care standards. 1 c. If I am pregnant my agent shall follow these specific instrtrition and hydration artificially. _____ I direct that my life not be extended by life-sustaining procedures, except that if I am unable to take in food by mouth, I wish to receive nutrition and hydrnd there is no reasonable expectation of my recovery within a medically appropriate period _____ I direct that my life not be extended by life-sustaining procedures, including the administration of nunt in accordance with accepted health care standards. b. If I am in a persistent vegetative state, that is if I am not conscious and am not aware of my environment nor able to interact with others, a, except that, if I am unable to take food by mouth, I wish to receive nutrition and hydration artificially. _____ I direct that, even in a terminal condition, I be given all available medical treatmet my life not be extended by life-sustaining procedures, including the administration of nutrition and hydration artificially. _____ I direct that my life not be extended by life-sustaining procedurestatements which do not apply.) a. If my death from a terminal condition is imminent and even if life-sustaining procedures are used there is no reasonable expectation of my recovery _____ I direct thaon regarding my health care, I direct my health care providers to follow my instructions as set forth below. (Initial those statements you wish to be included in the document and cross through those so the Disclaimers and Terms of Use found at findlegalforms.com A statement of medications preferred by the declarant for psychiatric treatment; Living Will If I am not able to make an informed decisi when dealing with estate planning matters. Any possible tax consequences arising out of this document should be discussed with a tax professional. [_] The purchase and use of these forms is subject tnly be a starting point for you and should not be used or signed without consulting an attorney first to make sure it fits your particular situation. Advice from a local attorney is always recommendeds to their legal effect or completeness. [_]These forms are not intended and are not a substitute for legal and/or tax advice. Laws vary from time to time and from state to state. These forms should oant has provided a copy of the directive. [_] These forms are provided "as is" and no implied or express warranties have been made or are provided as to their suitability for any specific purpose or a the substance of the oral revocation in the declarant's medical record. (c) It shall be the responsibility of the declarant, to the extent reasonably possible, to notify any person to whom the declartion of a subsequent directive. (b) If a declarant revokes an advance directive by an oral statement to a health care practitioner, the practitioner and a witness to the oral revocation shall documentn advance directive may be revoked at any time by a declarant by a signed and dated writing, by physical cancellation or destruction, by an oral statement to a health care practitioner or by the execulth services; (3) and (4) Instruction regarding the notification of third parties and the release of information to third parties about mental health services provided to the declarant. § 5-604. (a) Ation of an agent to make mental health services decisions for the (2) The identification of mental health professionals, programs, and facilities that the declarant would prefer to provide mental heato the revocation of an advance directive for mental health services. (d) An advance directive for mental health services may include: Information & Instructions ­ Page 6 (1) declarant; The designae procedures for making an advance directive provided under § 5-602 of this subtitle. (2) The procedures provided under § 5-604 of this subtitle for the revocation of an advance directive shall apply s incompetent and has a need for mental health services either during, or as a result of, the incompetency. (c) (1) An individual making an advance directive for mental health services shall follow thn § 4-301(i)(1) of this article. (b) An individual who is competent may make an advance directive to outline the mental health services which may be provided to the individual if the individual becomedvance directive creates no presumption as to the patient's intent to consent to or refuse life-sustaining procedures. § 5-602.1. (a) In this section, "mental health services" has the meaning stated ilarant's behalf. (h) Unless otherwise provided in the patient's advance directive, a patient's agent shall act in accordance with the provisions of § 5-605(c) of this subtitle. (i) The absence of an aan, a part of the declarant's medical records. (g) It shall be the responsibility of the declarant to notify a health care agent that the agent has been named in an advance directive to act on the declarant's medical records; or (ii) If the advance directive is oral, make the substance of the advance directive, including the date the advance directive was made and the name of the attending physiciician who is notified of the existence of the advance directive shall promptly: (i) If the advance directive is written, make the advance directive or a copy of the advance directive a part of the deche event the declarant becomes comatose, incompetent, or otherwise incapable of communication, any other person may notify the physician of the existence of an advance directive. (2) An attending physhysician is not required under paragraph (1) of this subsection. (f) (1) It shall be the responsibility of the declarant to notify the attending physician that an advance directive has been made. In tt Information & Instructions ­ Page 5 the patient is incapable of making an informed decision. (2) If a patient is unconscious, or unable to communicate by any means, the certification of a second pn and the witness. (e) (1) Unless otherwise provided in the document, an advance directive shall become effective when the declarant's attending physician and a second physician certify in writing thaician and one witness and if the substance of the oral advance directive is documented as part of the individual's medical record. The documentation shall be dated and signed by the attending physiciaappoint an agent to make health care decisions for the individual. (2) An oral advance directive shall have the same effect as a written advance directive if made in the presence of the attending physeason of the death of the declarant. (d) (1) Any competent individual may make an oral advance directive to authorize the providing, withholding, or withdrawing of any life-sustaining procedure or to as a witness. (iii) At least one of the witnesses must be an individual who is not knowingly entitled to any portion of the estate of the declarant or knowingly entitled to any financial benefit by rtness to an advance directive, including an employee of a health care facility or physician caring for the declarant if acting in good faith. (ii) The health care agent of the declarant may not serve igned by or at the express direction of the declarant, and subscribed by two witnesses. (2) (i) Except as provided in items (ii) and (iii) of this paragraph, any competent individual may serve as a wisubtitle has decision making priority over any individuals otherwise authorized under this subtitle to make health care decisions for a declarant. (c) (1) A written advance directive shall be dated, slarant is receiving health care may not serve as a health care agent unless the person would qualify as a surrogate decision maker under § 5-605(a) of this subtitle. (3) An agent appointed under this ting an agent to make health care decisions for the individual under the circumstances stated in the advance directive. (2) An owner, operator, or employee of a health care facility from which the decsion of health care to that individual, or the withholding or withdrawal of health care from that individual. (b) (1) Any competent individual may, at any time, make a written advance directive appoinrom which, despite the application of life-sustaining procedures, there can be no recovery. § 5-602. (a) Any competent individual may, at any time, make a written advance directive regarding the provition & Instructions ­ Page 4 (q) "Terminal condition" means an incurable condition caused by injury, disease, or illness which, to a reasonable degree of medical certainty, makes death imminent and fl certainty, that there can be no recovery. (p) "Physician" means a person licensed to practice medicine in the State or in the jurisdiction where the treatment is to be rendered or withheld. Informativity of muscles and nerves for low level conditioned response; and (2) From which, after the passage of a medically appropriate period of time, it can be determined, to a reasonable degree of medicaase, or illness: (1) In which a patient has suffered a loss of consciousness, exhibiting no behavioral evidence of self-awareness or awareness of surroundings in a learned manner other than reflex ac (1) (2) (o) Prevent or reduce the deterioration of the health of an individual; or Prevent the impending death of an individual. "Persistent vegetative state" means a condition caused by injury, disely administered hydration and nutrition, and cardiopulmonary resuscitation. (n) "Medically ineffective treatment" means that, to a reasonable degree of medical certainty, a medical procedure will not: nature as to afford a patient no reasonable expectation of recovery from a terminal condition, persistent vegetative state, or end-stage condition. (2) "Life-sustaining procedure" includes artificialre" means any medical procedure, treatment, or intervention that: (i) Utilizes mechanical or other artificial means to sustain, restore, or supplant a spontaneous vital function; and (ii) Is of such apurposes of this subtitle, a competent individual who is able to communicate by means other than speech may not be considered incapable of making an informed decision. (m) (1) "Life-sustaining proceduatment or course of treatment, is unable to make a rational evaluation of the burdens, risks, and benefits of the treatment or course of treatment, or is unable to communicate a decision. (2) For the rovision, withholding, or withdrawal of a specific medical treatment or course of treatment because the patient is unable to understand the nature, extent, or probable consequences of the proposed trepractitioner or a facility that provides health care to individuals. (l) (1) "Incapable of making an informed decision" means the inability of an adult patient to make an informed decision about the pmeans a health care practitioner or a facility that provides health care to individuals. Information & Instructions ­ Page 3 (2) "Health care provider" includes agents or employees of a health care of the Education Article 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" , treatment of the irreversible condition would be medically ineffective. (j) "Health care practitioner" means: (1) An individual licensed or certified under the Health Occupations Article or § 13516, disease, or illness: (1) That has caused severe and permanent deterioration indicated by incompetency and complete physical dependency; and (2) For which, to a reasonable degree of medical certaintyment techniques, artificial ventilation, defibrillation, and other related life-sustaining procedures. (i) "End-stage condition" means an advanced, progressive, irreversible condition caused by injuryes certified or licensed emergency medical services personnel to withhold or withdraw cardiopulmonary resuscitation including cardiac compression, endotracheal intubation, other advanced airway manageand Institute for Emergency 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, authorizle of making and communicating 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 Maryl to consent to medical treatment 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 capabst the decision maker in determining 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 adultcts, and benefits of the treatment 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 assiuctions ­ Page 2 (4) (5) 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 efferawal 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; Information & Instrort 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 withholding or withdal resulting from that treatment, taking into account: (1) The effect of the treatment on the physical, emotional, and cognitive functions of the individual; (2) The degree of physical pain or discomf 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 individuinted 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 physicianarant 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 adult appoating to Living Wills. § 5-601. (a) In this subtitle the following words have the meanings indicated. (b) "Advance directive" means: (1) A witnessed written document, voluntarily executed by the declving Will. This Maryland Living Will is based on the following Maryland Statutes: "Health General § 5601 et. Seq." For your convenience, we have included useful excerpts from the Maryland Statutes relminent despite the application of lifesustaining procedures or you are in a persistent vegetative state. This package contains (1) Information and Instruction for Maryland Living Will; (2) Maryland LiInformation and Instructions Maryland Living Will This Living Will form allows you to make some decisions about life-sustaining procedures if, in the future, your death from a terminal condition is im MarylandMaryland ____________________ Phone: _______________________________________ Date: ________________ -3- _________________________________ Date: ________________ _____________________________________________ (Witness Signature) Print Name: ___________________________________ Address: __________________petent individual. -2- _____________________________________________ (Witness Signature) Print Name: ___________________________________ Address: ______________________________________ Phone: ______ benefit by reason of Declarant's death). The declarant signed or acknowledged signing this appointment of a health care agent in my presence and based upon my personal observation appears to be a comd its purpose and effect. ______________________ (Date) ____________________________________________ (Signature of Declarant) (At least one of your witnesses may not be a person who may financiallyor 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 and that I understants, 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 shall not be liable f 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 considering the benefith 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 wishes as otherwiserity becomes operative (initial the option that applies): ___________ When my attending physician and a second physician determine that I am incapable of making an informed decision regarding my heal______________________ _____________________________________________________________________________ _____________________________________________________________________________ (4) My agent's authostances, life-sustaining procedures. -1- (3) The authority of my agent is subject to the following provisions and limitations (or write none): _______________________________________________________ facility) any hospital, hospice, nursing home, adult home, or other medical care facility; and d. Consent to the provision, withholding, or withdrawal of health care, including, in appropriate circumcal 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 transfer to anothermake 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 not limited to, medi_________________________________ _____________________________________________________________________________ (Full Name, Address, and Telephone Number) (2) My agent has full power and authority to e 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 ____________________________________________ns for me: _____________________________________________________________________________ _____________________________________________________________________________ (Full Name, Address, and Telephon____________________________________, residing at _____________________________________________________________________________ appoint the following individual as my agent to make health care decisio 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 this document.) (1) I, ____________________________of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com. -6- Power of Attorney for Health Care Appointment of Health Care Agent (If you do want to appoint an agent,orney is always recommended when dealing with estate planning matters. Any possible tax consequences arising out of this document should be discussed with a tax professional. [_] The purchase and use state. These forms should only be a starting point for you and should not be used or signed without consulting an attorney first to make sure it fits your particular situation. Advice from a local attr any specific purpose or as to their legal effect or completeness. [_]These forms are not intended and are not a substitute for legal and/or tax advice. Laws vary from time to time and from state to y person to whom the declarant has provided a copy of the directive. [_] These forms are provided "as is" and no implied or express warranties have been made or are provided as to their suitability fol revocation shall document the substance of the oral revocation in the declarant's medical record. (c) It shall be the responsibility of the declarant, to the extent reasonably possible, to notify anractitioner or by the execution of a subsequent directive. (b) If a declarant revokes an advance directive by an oral statement to a health care practitioner, the practitioner and a witness to the ora treatment; § 5-604. (a) An advance directive may be revoked at any time by a declarant by a signed and dated writing, by physical cancellation or destruction, by an oral statement to a health care pification of third parties and the release of information to third parties about mental health services provided to the declarant. A statement of medications preferred by the declarant for psychiatricns for the (2) The identification of mental health professionals, programs, and facilities that the declarant would prefer to provide mental health services; (3) and (4) Instruction regarding the notvance directive for mental health services. -5- (d) An advance directive for mental health services may include: (1) declarant; The designation of an agent to make me ntal health services decisio advance directive provided under § 5-602 of this subtitle. (2) The procedures provided under § 5-604 of this subtitle for the revocation of an advance directive shall apply to the revocation of an aded for mental health services either during, or as a result of, the incompetency. (c) (1) An individual making an advance directive for mental health services shall follow the procedures for making anticle. (b) An individual who is competent may make an advance directive to outline the mental health services which may be provided to the individual if the individual becomes incompetent and has a ne presumption as to the patient's intent to consent to or refuse life-sustaining procedures. § 5-602.1. (a) In this section, "mental health services" has the meaning stated in § 4-301(i)(1) of this ar otherwise provided in the patient's advance directive, a patient's agent shall act in accordance with the provisions of § 5-605(c) of this subtitle. (i) The absence of an advance directive creates nos medical records. (g) It shall be the responsibility of the declarant to notify a health care agent that the agent has been named in an advance directive to act on the declarant's beha lf. (h) Unless (ii) If the advance directive is oral, make the substance of the advance directive, including the date the advance directive was made and the name of the attending physician, a part of the declarant' existence of the advance directive shall promptly: (i) If the advance directive is written, make the advance directive or a copy of the advance directive a part of the declarant's medical records; ores comatose, incompetent, or otherwise incapable of communication, any other person may notify the physician of the existence of an advance directive. (2) An attending physician who is notified of theer paragraph (1) of this subsection. (f) (1) It shall be the responsibility of the declarant to notify the attending physician that an advance directive has been made. In the event the declarant becomriting that the patient is incapable of making an informed decision. (2) If a patient is unconscious, or unable to communicate by any means, the certification of a second physician is not required undician and the witness. -4- (e) (1) Unless otherwise provided in the document, an advance directive shall become effective when the declarant's attending physician and a second physician certify in wphysician and one witness and if the substance of the oral advance directive is documented as part of the individual's medical record. The documentation shall be dated and signed by the attending phys to appoint an agent to make health care decisions for the individual. (2) An oral advance directive shall have the same effect as a written advance directive if made in the presence of the attending by reason of the death of the declarant. (d) (1) Any competent individual may make an oral advance directive to authorize the providing, withholding, or withdrawing of any life-sustaining procedure orrve as a witness. (iii) At least one of the witnesses must be an individual who is not knowingly entitled to any portion of the estate of the declarant or knowingly entitled to any financial benefit a witness to an advance directive, including an employee of a health care facility or physician caring for the declarant if acting in good faith. (ii) The health care agent of the declarant may not sed, signed by or at the express direction of the declarant, and subscribed by two witnesses. (2) (i) Except as provided in items (ii) and (iii) of this paragraph, any competent individual may serve as his subtitle has decision making priority over any individuals otherwise authorized under this subtitle to make health care decisions for a declarant. (c) (1) A written advance directive shall be date declarant is receiving health care may not serve as a health care agent unless the person would qualify as a surrogate decision maker under § 5-605(a) of this subtitle. (3) An agent appointed under tpointing an agent to make health care decisions for the individual under the circumstances stated in the advance directive. (2) An owner, operator, or employee of a health care facility from which therovision of health care to that individual, or the withholding or withdrawal of health care from that individual. (b) (1) Any competent individual may, at any time, make a written advance directive apd from which, despite the application of life-sustaining procedures, there can be no recovery. § 5-602. (a) Any competent individual may, at any time, make a written advance directive regarding the pt is to be rendered or withheld. (q) "Terminal condition" means an incurable condition caused by injury, disease, or illness which, to a reasonable degree of medical certainty, makes death imminent and, to a reasonable degree of medical certainty, that there can be no recovery. -3- (p) "Physician" means a person licensed to practice medicine in the State or in the jurisdiction where the treatmenlearned manner other than reflex activity of muscles and nerves for low level conditioned response; and (2) From which, after the passage of a medically appropriate period of time, it can be determine a condition caused by injury, disease, or illness: (1) In which a patient has suffered a loss of consciousness, exhibiting no behavioral evidence of self-awareness or awareness of surroundings in a inty, a medical procedure will not: (1) (2) (o) Prevent or reduce the deterioration of the health of an individual; or Prevent the impending death of an individual. "Persistent vegetative state" meansning procedure" includes artificially administered hydration and nutrition, and cardiopulmonary resuscitation. (n) "Medically ineffective treatment" means that, to a reasonable degree of medical certatal function; and (ii) Is of such a nature as to afford a patient no reasonable expectation of recovery from a terminal condition, persistent vegetative state, or end-stage condition. (2) "Life-sustain. (m) (1) "Life-sustaining procedure" means any medical procedure, treatment, or intervention that: (i) Utilizes mechanical or other artificial means to sustain, restore, or supplant a spontaneous viommunicate a decision. (2) For the purposes of this subtitle, a competent individual who is able to communicate by means other than speech may not be considered incapable of making an informed decisiole consequences of the proposed treatment or course of treatment, is unable to make a rational evaluation of the burdens, risks, and benefits of the treatment or course of treatment, or is unable to cke an informed decision about the provision, withholding, or withdrawal of a specific medical treatment or course of treatment because the patient is unable to understand the nature, extent, or probabents or employees of a health care practitioner or a facility that provides health care to individuals. (l) (1) "Incapable of making an informed decision" means the inability of an adult patient to maator in accordance with hospital policy. (k) (1) "Health care provider" means a health care practitione r or a facility that provides health care to individuals. (2) "Health care provider" includes agnsed or certified under the Health Occupations Article or § 13516 of the Ed ucation Article to provide health care; or -2- (2) The administrator of a hospital or a person designated by the administry; and (2) For which, to a reasonable degree of medical certainty, treatment of the irreversible condition would be medically ineffective. (j) "Health care practitioner" means: (1) An individual licean advanced, progressive, irreversible condition caused by injury, disease, or illness: (1) That has caused severe and permanent deterioration indicated by incompetency and complete physical dependencompression, endotracheal intubation, other advanced airway management techniques, artificial ventilation, defibrillation, and other related life-sustaining procedures. (i) "End-stage condition" means a cardiac or respiratory arrest of a particular patient, authorizes certified or licensed emergency medical services personnel to withhold or withdraw cardiopulmonary resuscitation including cardiac citten order in a form established by protocol issued by the Maryland Institute for Emergency Medical Services in conjunction with the State Board of Physician Quality Assurance which, in the event of a competent individual who makes an advance directive while capable of making and communicating an informed decision. (h) "Emergency medical services `do not resuscitate order'" means a physician's wrder § 20-102(a) of this article has the same capacity as an adult to consent to medical treatment and who has not been determined to be incapable of making an informed decision. (g) "Declarant" means the individual receiving treatment, to the extent these may assist the decision maker in determining best interest. (f) "Competent individual" means a person who is at least 18 years of age or who uncovery, with and without the treatment; (6) The risks, side effects, and benefits of the treatment or the withholding or withdrawal of the treatment; and (7) The religious beliefs and basic values of by subjecting the individual to a condition of extreme humiliation and dependency; (4) (5) The effect of the treatment on the life expectancy of the individual; The prognosis of the individual for re (3) The degree to which the individual's medical condition, the treatment, or the withholding or withdrawal of treatment result in a severe and continuing impairment of the dignity of the individual, emotional, and cognitive functions of the individual; (2) The degree of physical pain or discomfort caused to the individual by the treatment, or the withholding or withdrawal of the treatment; -1-hat the benefits to the individual resulting from a treatment outweigh the burdens to the individual resulting from that treatment, taking into account: (1) The effect of the treatment on the physicaltle to make health care decisions for the declarant. (d) "Attending physician" means the physician who has primary responsibility for the treatment and care of the patient. (e) "Best interest" means t the declarant in accordance with the provisions of this subtitle. (c) "Agent" means an adult appointed by the declarant under an advance directive made in accordance with the provisions of this subtied. "Advance directive" means: (1) A witnessed written document, voluntarily executed by the declarant in accordance with the requirements of this subtitle; or (2) A witnessed oral statement, made by§ 5-601 et. Seq." For your convenience, we have included useful relevant excerpts from the relevant Maryland Statutes. § 5-601. (a) (b) In this subtitle the following words have the meanings indicatwitnesses may not be a person who may financially benefit by reason of your death. This Maryland Power of Attorney for Health Care is based in part on the following Maryland Statutes: "Health General ntains (1) Information and Instruction for Maryland Power of Attorney for Health Care; (2) Maryland Power of Attorney for Health Care. The health care agent may not be a witness. At least one of your ou to select and appoint a health care agent to make decisions about life-sustaining procedures in the event of terminal condition, persistent vegetative state, or end-stage condition. This package coInformation and Instructions Maryland Power of Attorney for Health Care The Maryland Power of Attorney for Health Care, allows you to make some decisions about future health care issues, by allowing y MarylandMaryland _________________ Name: _______________________________________________ Address: ____________________________________________ City: _______________________________________________ State: ______________________________: _______________________________________________ State: _______________________________________________ SECOND WITNESS: Date: __________________ Signature: ___________________________________________ITNESS: Date: __________________ Signature: ___________________________________________ Name: _______________________________________________ Address: ____________________________________________ Cityion and in the presence of the Donor and each other. The individual signing the Donation of Gift was directed to do so by the Donor and signed the document in his/her presence as well as ours. FIRST Wnd by two witnesses, all of whom have signed at the direction and in the presence of the donor and of each other, and state that it has been so signed.] Witness Statement: We have signed at the direct____________________ WITNESS FORM [An anatomical gift may be made only by a document of gift signed by the donor. If the donor cannot sign, the document of gift must be signed by another individual a_ Print your name: ______________________________________ Address: ____________________________________________ City: _______________________________________________ State: ___________________________n, surgeon, technician, or enucleator to carry out the appropriate procedures. SIGNATURE: (Sign and date the form here:) Date: __________________ Sign your name: _____________________________________the appropriate procedures. In the absence of a designation or if the designee is not available, the donee or other person authorized to accept the anatomical gift may employ or authorize any physiciaof the following you do not want): (1) Transplant (2) Therapy (3) Research (4) Education (Optional) I designate ___________________________________ as my particular physician or surgeon to carry out __ ________________________________________________________________________ ________________________________________________________________________ My gift is for the following purposes (strike any x): Give any needed organs, tissues, or parts, OR Give the following organs, tissues, or parts only: ____________________________ ______________________________________________________________________ for all serious legal matters. Anatomical Gift by Living Donor Pursuant to Uniform Anatomical Gift Act Upon my death, I ____________________________________ (the "Donor"), hereby (mark applicable boand on any theory of liability, whether in contract, strict liability, or tort (including negligence or otherwise) arising in any way out of the use of these materials. An attorney should be consultedntal, special, exemplary, or consequential damages (including, but not limited to, procurement of substitute goods or services; loss of use, data, or profits; or business interruption) however caused risk. In no event will: i) FindLegalForms, Inc, its agents, partners, or affiliates, or ii) the providers, authors or publishers of the forms, be responsible or liable for any direct, indirect, incideovided "AS-IS." We do not give any express or implied warranties of merchantability, suitability or completeness for any of the materials for your particular needs. The materials are used at your own erials. FindLegalForms, Inc. does not provide legal advice. The purchase and use of these materials is subject to the "Disclaimers and Terms of Use" found at findlegalforms.com. These materials are pran anatomical gift. During a terminal illness or injury, the refusal may be an oral statement or other form of communication. Disclaimer No Attorney-Client relationship is created by use of these matocument of gift, (ii) a statement attached to or imprinted on a donor's motor vehicle operator's or chauffeur's license, or (iii) any other writing used to identify the individual as refusing to make the consent or concurrence of any person after the donor's death. An individual may refuse to make an anatomical gift of the individual's body or part by (i) a writing signed in the same manner as a ddelivery of a signed statement to a specified donee to whom a document of gift had been delivered. An anatomical gift that is not revoked by the donor before death is irrevocable and does not require ) a signed statement; (2) an oral statement made in the presence of two individuals; (3) any form of communication during a terminal illness or injury addressed to a physician or surgeon; or (4) the f, after death, the will is declared invalid for testamentary purposes, the validity of the anatomical gift is unaffected. A donor may amend or revoke an anatomical gift, not made by will, only by: (1ze any physician, surgeon, technician, or enucleator to carry out the appropriate procedures. An anatomical gift by will takes effect upon death of the testator, whether or not the will is probated. In to carry out the appropriate procedures. In the absence of a designation or if the designee is not available, the donee or other person authorized to accept the anatomical gift may employ or authories, all of whom have signed at the direction and in the presence of the donor and of each other, and state that it has been so signed. A document of gift may designate a particular physician or surgeo least 18 years of age. An anatomical gift may be made by a document of gift signed by the donor. If the donor cannot sign, the document of gift must be signed by another individual and by two witness Instructions for preparing your Anatomical Gift Anatomical Gift Form To make an anatomical gift, limit an anatomical gift or refuse to make an anatomical gift, an individual must in most cases be atvides tools and guidelines to assist you in creating your Anatomical Gift and is designed to fulfill the obligations of the Uniform Anatomical Gift Act. Included in this kit are the following: Generalour wishes regarding the disposition of your body will be ignored. By preparing a written Anatomical Gift, you can rest assured that your desire to donate your organs will be carried out. This kit proFindLegalForms.com Information Donation Pursuant to the Uniform Anatomical Gift Act (by Living Donor) No one likes considering their own death, but by avoiding the subject, it is likely that many of y MarylandMaryland ________ n whose name is subscribed to this instrument appears to be of sound mind and under no duress, fraud, or undue influence. _____________________________ Notary Public My commission expires ____________ersonally and, under oath, stated that he or she is the person described in the above document and he or she signed the above document in my presence. I declare under penalty of perjury that the perso_________________________________ Notary Acknowledgment (Optional) State of ____________________ County of ____________________ On ____________________, ______________________________ came before me pignature of Donor ______________________________ Printed Name of Donor Address: ____________________________________________ City: _______________________________________________ State: ______________y written revocation of my Anatomical Gift. This statement will be delivered to all specified donees, if any, to whom a document of gift had been previously delivered. ______________________________ Sication during a terminal illness or injury addressed to a physician or surgeon; or (4) the delivery of a signed statement to a specified donee to whom a document of gift had been delivered. This is m of this state, a donor may amend or revoke an anatomical gift, not made by will, only by: (1) a signed statement; (2) an oral statement made in the presence of two individuals; (3) any form of commun__________________, I, ______________________________, the donor, fully and completely revoke the Anatomical Gift dated __________________________. Pursuant to Uniform Anatomical Gift Act and the lawsft Act, you should check the laws of your state to determine whether there are any other requirements you must meet to revoke your Anatomical Gift. Revocation of Anatomical Gift On this date ________estroy the original and all copies of your Anatomical Gift or cross out each page of the forms and mark "REVOKED" across them in bold print. Although most states have adopted the Uniform Anatomical Giorm notarized. You should also make certain that a copy of any revocation is provided to anyone who has a copy of your original Anatomical Gift, including any designated donees. You should also then dted. When you have completed the form and printed it, sign the form and make certain that you store the original where you had stored the original of your Anatomical Gift. You may choose to have the f. An anatomical gift that is not revoked by the donor before death is irrevocable and does not require the consent or concurrence of any person after the donor's death. Complete the information requesm of communication during a terminal illness or injury addressed to a physician or surgeon; or (4) the delivery of a signed statement to a specified donee to whom a document of gift had been deliveredn of Anatomical Gift form. A donor may amend or revoke an anatomical gift, not made by will, only by: (1) a signed statement; (2) an oral statement made in the presence of two individuals; (3) any foray out of the use of these materials. An attorney should be consulted for all serious legal matters. Revoking Your Anatomical Gift Instructions Following these instructions, you will find a Revocatios of use, data, or profits; or business interruption) however caused and on any theory of liability, whether in contract, strict liability, or tort (including negligence or otherwise) arising in any w the forms, be responsible or liable for any direct, indirect, incidental, special, exemplary, or consequential damages (including, but not limited to, procurement of substitute goods or services; loserials for your particular needs. The materials are used at your own risk. In no event will: i) FindLegalForms, Inc, its agents, partners, or affiliates, or ii) the providers, authors or publishers ofand Terms of Use" found at findlegalforms.com. These materials are provided "AS-IS." We do not give any express or implied warranties of merchantability, suitability or completeness for any of the matlaimer No Attorney-Client relationship is created by use of these materials. FindLegalForms, Inc. does not provide legal advice. The purchase and use of these materials is subject to the "Disclaimers esigned to fulfill the requirements of the Uniform Anatomical Gift Act. Included in this kit is the following: General Instructions for Revoking Your Anatomical Gift Revocation of Anatomical Gift Discnt to revoke the document. Until your death, it is your right to revoke your Anatomical Gift at any time. This kit provides tools and guidelines to assist you in revoking your Anatomical Gift and is dFindLegalForms.com Information Revoking an Anatomical Gift (Organ Donation Revocation) You prepared a written Anatomical Gift, but now because of a change of circumstances or a change of heart, you wa MarylandMaryland _____________ 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 Maryland