$23.95

Add to cart

Mississippi ddress: ______________________________________ Social Security Number:__________________________ _________________________________ Social Security Number:__________________________ _____________________________________________ (Witness Signature) Print Name: ___________________________________ Aperson employed by a physician attending the maker of this revocation. _____________________________________________ (Witness Signature) Print Name: ___________________________________ Address: _____ revocation, (c) Am not entitled to any portion of the estate of the maker of this revocation by any will or by operation of law, and (d) Am not a physician attending the maker of the revocation or a my knowledge, at the time of the execution of this revocation, I: (a) Am not related to the maker of this revocation by blood or ma rriage, (b) Do not have any claim on the estate of the maker of this________________ I hereby witness this revocation and attest that: (1) I personally know the maker of this revocation and believe the maker of this revocation to be of sound mind. (2) To the best of _________________________ (Social Security Number), being of sound mind, revoke the declaration made on ______________ (date declaration made) regarding the manner in which I die. SIGNED ____________ Revocation Of Declaration On ______________ (date), I, _____________________________________________ (person's name), of _____________________________________________________________ (address), _______________________________________________ (Witness Signature) Print Name: ________________________________ Address: ___________________________________ Social Security Number: _______________________________________________________________ (Witness Signature) Print Name: ________________________________ Address: ___________________________________ Social Security Number: ______________________ ntitled to any portion of the Declarant's estate by any will or by operation of law, and (d) Am not a physician attending the Declarant or a person employed by a physician attending the Declarant. __t of my knowledge, at the time of the execution of this declaration, I: (a) Am not related to the Declarant by blood or marriage, (b) Do not have any claim on the estate of the Declarant, (c) Am not e which I die. SIGNED ____________________________ I hereby witness this declaration and attest that: (1) I personally know the Declarant and believe the Declarant to be of sound mind. (2) To the besforce or effect during the course of my pregnancy. I further declare that this declaration shall be honored by my family and my physician as the final expression of my desires concerning the manner ininent, I desire that the mechanisms be withdrawn so that I may die naturally. However, if I have been diagnosed as pregnant and that diagnosis is known to my physician, this declaration shall have no er physicians, believes that there is no expectation of my regaining consciousness or a state of health that is meaningful to me and but for the use of life-sustaining mechanisms my death would be immbeing of sound mind, declare that if at any time I should suffer a terminal physical condition which causes me severe distress or unconsciousness, and my physician, with the concurrence of two (2) othrson's name) of ________________________________________________________ (address), ____________________________ (Social Security Number). I, ________________________________________________________ urchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Living Will DECLARATION made on ______________ (date) by ________________________________ (pefrom a local attorney is always recommended when dealing with estate planning matters. Any possible tax consequences arising out of this document should be discussed with a tax professional. [_] The pd from state to state. These forms should only be a starting point for you and should not be used or signed without consulting an attorney first to make sure it fits your particular situation. Advice r suitability for any specific purpose or as to their legal effect or completeness. [_]These forms are not intended and are not a substitute for legal and/or tax advice. Laws vary from time to time anphysician's determination of Declarant's response in such situations shall be final. [_] These forms are provided "as is" and no implied or express warranties have been made or are provided as to theiant, prior to procedures which might reasonably be expected to cause the Declarant to become permanently unconscious or unable to make his wishes known, if said Declarant revokes his declaration. The the authorization. (4) An attending physician having actual knowledge or reason to believe that his patient has executed a declaration in conformance with sections 41-41-101 et seq. may ask the Declarically to execute a revocation as provided in this section, a clear expression by the Declarant, oral or otherwise, of the Declarant's wish to revoke the authorization is effective as a revocation of ) The revocation shall be filed with the bureau of vital statistics of the state board of health. (3) If a Declarant wishes to revoke the authorization of life-sustaining mechanisms but is unable physa revocation signed by the Declarant and at least two (2) persons who witnessed the Declarant's execution of the revocation which shall be in substantially the following form: (Form included below) (2filed with the bureau of vital statistics of the state board of health. SEC. 41-41-109. Revocation of declaration; form. (1) A declaration executed as provided in section 41-41-107 may be revoked by gned by at least two (2) persons who witnessed the execution of the declaration by the Declarant which shall be in substantially the following form: (Form included below) (2) The declaration shall be ion upon the death of the Declarant or maker of the revocation. SEC. 41-41-107. Declaration of intent; form. (1) The authorization for withdrawal of life-sustaining mechanisms must be a declaration siformation & Instructions ­ Page 2 (d) Persons who at the time of the execution of the declaration or revocation have a claim against any portion of the estate of the Declarant or maker of the revocatation or revocation; or (c) The attending physician or an employee of the attending physician or of a health facility in which the Declarant or maker of the revocation is a patient; or Living Will Inate of the Declarant or maker of the revocation upon his decease under any will or codicil of the Declarant or maker of the revocation or by operation of law at the time of the execution of the declarg witnesses who, at the time the declaration or revocation is executed, are not: (a) Related to the Declarant or maker of the revocation by blood or marriage; or (b) Entitled to any portion of the estsection 4141-109, except for the type of revocation provided by section 41-41-109 (3), are valid only if signed by the Declarant or maker of the revocation in the presence of at least two (2) attestinwithdrawal of life-sustaining mechanisms. SEC. 41-41-111. Signature of Declarant or maker of revocation; witnesses. A declaration made pursuant to section 41-41-107 and a revocation made pursuant to evices, which prolong life through artificial means. SEC. 41-41-105. Age requirement; mental competency. Any person of the age of eighteen (18) years or older who is mentally competent may authorize dicine in any state in the United States of America. (b) "Withdrawal of life-sustaining mechanisms" shall mean the cessation of use of extraordinary techniques and applications, including mechanical d. For purposes of Secs. 41-41-101 et seq., the following words shall have the meaning ascribed herein unless the context otherwise requires: (a) "Physician" shall mean a person licensed to practice mer 041 Section 41-41103 et. Seq. of the Mississippi Statutes. For your convenience, we have included useful excerpts from the Mississippi Statutes relating to Living Wills. SEC. 41-41-103. Definitionsnd Instruction for Mississippi Living Will; (2) Mississippi Living Will; (3) Revocation of Declaration (Living Will Revocation). The Mississippi Living Will and Revocation are based on Title 41 Chapte Notary Seal _____________________________________________ (Signature of Notary Public) -4- Information and Instructions Mississippi Living Will & Revocation This package contains (1) Information aat he or she executed it. I declare under the penalty of perjury that the person whose name is subscribed to this instrument appears to be of sound mind and under no duress, fraud or undue influence. ______________________________________, personally known to me (or proved to me on the basis of satisfactory evidence) to be the person whose name is subscribed to this instrument, and acknowledged th_ ) On this ______________, day of _____________________, in the year __________, before me, _____________________________________________________, (insert name of notary public) appeared ______________ Address: ______________________________________ Phone: _______________________________________ -3- Notary (optional instead of Witnesses) State of Mississippi ) ) County of ___________________ I am not a health care provider, nor an employee of a health care provider or facility. _____________________________________________ (Witness Signature) Print Name: ________________________________attorney in my presence, that the principal appears to be of sound mind and under no duress, fraud or undue influence, that I am not the person appointed as attorney in fact by this document, and that_______________________ I declare under penalty of perjury under the laws of Mississippi that the principal is personally known to me, that the principal signed or acknowledged this durable power of ation of law. _____________________________________________ (Witness Signature) Print Name: ___________________________________ Address: ______________________________________ Phone: ________________cipal by blood, marriage or adoption, and to the best of my knowledge, I am not entitled to any part of the estate of the principal upon the death of the principal under a will now existing or by opere, that I am not the person appointed as attorney in fact by this document, and that I am not a health care provider, nor an employee of a health care provider or facility I am not related to the prinonally known to me, that the principal signed or acknowledged this durable power of attorney in my presence, that the principal appears to be of sound mind and under no duress, fraud or undue influence your signature or (b) acknowledged before a notary public in the state Witness Declarations and Signature I declare under penalty of perjury under the laws of Mississippi that the principal is persy will not be valid for making health care decisions unless it is either (a) signed by two (2) qualified adult witnesses who are personally known to you and who are present when you sign or acknowledgat I understand the purpose and effect of this document. Signed: ____________________________________________________________________ Dated: ______________________________ -2- This power of attorne_______________________________________________ _________________________________ Work Telephone Number _________________________________ Home Telephone Number By my signature I do hereby indicate thact as my attorney in fact, I appoint the following person to serve in his or her place: Name:________________________________________________________________________ Home Address: ______________________________________________________________ ______________________________________________________________________________ If the person named as my attorney in fact is not available or is unable to r amended, being the statutes governing the withdrawal of life-saving mechanisms. Special instructions: _____________________________________________________________ __________________________________sonnel, get information and sign forms necessary to carry out these decisions, and also the power provided in Sections 41-41-101 through 41-41-121, Mississippi Code of 1972, as now enacted or hereaftee, to make a disposition under the state's anatomical gift act, to authorize an autopsy, and to direct the disposition of remains. My attorney in fact also has the authority to talk to health care perter my death, to the same extent I could make decisions for myself and to the full extent permitted by law, including power to grant, refuse or withdraw consent on my behalf for any health care serviconsent with respect to a given health care decision. Subject to my special instructions below, this document gives my attorney in fact the full power to make health care decisions for me, before or af_____________ Work Telephone Number _________________________________ Home Telephone Number as my attorney in fact to make health care decisions for me in the event I become unable to give informed came), hereby appoint: Name:________________________________________________________________________ Home Address: _________________________________________________________________ ____________________gn or acknowledge your signature or (b) acknowledged before a notary public in the state. -1- DURABLE POWER OF ATTORNEY FOR HEALTH CARE I, ________________________________________________________ (npower of attorney will not be valid for making health care decisions unless it is either (a) signed by two (2) qualified adult witnesses who are personally known to you and who are present when you siapeutic or scientific purposes, and (c) direct the disposition of your remains. If there is anything in this document that you do not understand, you should ask your lawyer to explain it to you. This u otherwise specify in this document, this document gives your agent the power after you die to (a) aut horize an autopsy, (b) donate your body or parts thereof for transplant or for educational, therer health care provider in writing of the revocation. Your agent has the right to examine your medical records and to consent to this disclosure unless you limit this right in this document. Unless yo are not known, does anything that is clearly contrary to your best interests. You have the right to revoke the authority of your agent by notifying your agent or your treating doctor, hospital or othrt can take away the power of your agent to make health care decisions for you if your agent (a) authorizes anything that is illegal, (b) acts contrary to your known desires, or (c) where your desiresower is subject to any statement of your desires and any limitations that you include in this document. You may state in this document any types of treatment that you do not desire. In addition, a count gives your agent authority to consent, to refuse to consent or to withdraw consent to any care, treatment, service or procedure to maintain, diagnose or treat a physical or mental condition. This pparticular decision. In addition, no treatment may be given to you over your objection, and health care necessary to keep you alive may not be stopped or withheld if you object at the time. The documeecessary to keep you alive. Notwithstanding this document, you have the right to make medical and other health care decisions for yourself so long as you can give informed consent with respect to the this document or otherwise made known. Except as you otherwise specify in this document, this document gives your agent the power to consent to your doctor not giving treatment or stopping treatment ndecisions for you. This power exists only as to those health care decisions to which you are unable to give informed consent. The attorney in fact must act consistently with your desires as stated in legal document. Before executing this document, you should kno w these important facts: This document gives the person you designate as the attorney in fact (your agent) the power to make health care and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com -4- Power of Attorney for Health Care NOTICE TO PERSON EXECUTING THIS DOCUMENT This is an important also consult an attorney whenever a document is negotiated with another party. Any possible tax consequences arising out of this document should be discussed with a tax professional. [_] The purchase nd should not be used without consulting with an attorney first. Before using or signing this document you should have an attorney review it to make sure it fits your particular situation. You should teness. [_]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 only be a starting point for you aocation. [_] 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 as to their legal effect or comple this section, a person is not subject to criminal prosecution or civil liability for acting in good faith reliance upon the durable power of attorney unless the person has actual knowledge of the rev a valid durable power of attorney for health care revokes any prior durable power of attorney for health care. (5) If authority granted by a durable power of attorney for health care is revoked underication a part of the principal's medical records. -3- (3) It is presumed that the principal has the capacity to revoke a durable power of attorney for health care. (4) Unless it provides otherwise,If the principal notifies the health care provider in writing that the authority granted to the attorney in fact to make health care decisions is revoked, the health care provider shall make the notif health care by notifying the attorney in fact in writing; (b) Revoke the authority granted to the attorney in fact to make health care decisions by notifying the health care provider in writing. (2) the capacity to give a durable power of attorney for health care, the principal may do any of the following: (a) Revoke the appointment of the attorney in fact under the durable power of attorney forower of attorney for health care: (a) A treating health care provider; (b) An employee of a treating health care provider. SEC. 41-41-171. Revocation of power. (1) At any time while the principal hassting. SEC. 41-41-161. Persons ineligible to be designated as attorney in fact. The following individuals may not be designated as the attorney in fact to make health care decisions under a durable phe principal upon his or her death under any will or codicil thereto of the principal existing at the time of execution of the durable power of attorney for health care or by operation of law then exiealth care shall be someone who is not one of the following: (a) A relative of the principal by blood, marriage or adoption; (b) An individual who would be entitled to any portion of the estate of tre provider; -2- (b) An employee of a health care provider or facility; or (c) The attorney in fact. (3) At least one (1) of the individuals used as a witness for a durable power of attorney for hndue influence. Notary Seal ---------------------------(Signature of Notary Public)" (2) None of the following may be used as witness for a durable power of attorney for health care: (a) A health ca acknowledged that he or she executed it. I declare under the penalty of perjury that the person whose name is subscribed to this instrument appears to be of sound mind and under no duress, fraud or uname of notary public) appeared ______________________, personally known to me (or proved to me on the basis of satisfactory evidence) to be the person whose name is subscribed to this instrument, andwithin this state, the notary public certifying to the substance of the following: "State of ----- ---"County of ----- ---On this ----- day of -----, in the year -----, before me, ---- ----- (insert am not entitled to any part of the estate of the principal upon the death of the principal under a will now existing or by operation of law." (ii) Be acknowledged before a notary public at any place ty." In addition, the declaration of at least one (1) of the witnesses must include the following: "I am not related to the principal by blood, marriage or adoption, and to the best of my knowledge, Iduress, fraud or undue influence, that I am not the person appointed as attorney in fact by this document, and that I am not a health care provider, nor an employee of a health care provider or facili---- that the principal is personally known to me, that the principal signed or acknowledged this durable power of attorney in my presence, that the principal appears to be of sound mind and under no principal or the principal's acknowledgement of the signature or of the instrument, each witness making the following declaration in substance: "I declare under penalty of perjury under the laws of --ntains the date of its execution and is witnessed by one (1) of the following methods: (i) Be signed by at least two (2) individuals each of whom witnessed either the signing of the instrument by the nly if the following requirements are satisfied: -1- (a) The durable power of attorney specifically authorizes the attorney in fact to make health care decisions; (b) The durable power of attorney cos health care decisions. SEC. 41-41-159. Requirements for attorney in fact to make health care decisions; persons who may witness for power. (1) An attorney in fact shall make health care decisions oe, a city, county, city and county or other public entity or governmental subdivision or agency or any other legal entity; (g) "Principal" shall mean the individual for which the attorney in fact makehe law of this state to administer health care in the ordinary course of business or practice of a profession; (f) "Person" shall include an individual, corporation, partnership, association, the station" shall mean consent, refusal of consent or withdrawal of consent to health care; (e) "Health care provider" shall mean a person who is licensed, certified or otherwise authorized or permitted by ts on behalf of the principal; (c) "Health care" shall mean any care, treatment, service or procedure to maintain, diagnose or treat an individual's physical or mental condition; (d) "Health care decised consent with respect to a given health care decision; (b) "Attorney in fact" shall mean one who is designated as an agent in a durable power of attorney for health care to make health care decision183: (a) "Durable power of attorney for health care" shall mean a document that authorizes an attorney in fact to make health care decisions for the principal if the principal is unable to give informng are useful excerpts from the Mississippi Statutes relating to the Mississippi Power of Attorney for Health Care Form. SEC. 41-41-155. Definitions. For purposes of Sections 41-41-151 through 41-41- Power of Attorney for Health Care Form. This Mississippi Durable Power of Attorney for Health Care is based on Title 41 Chapter 041 Section 41-41-163 et. Seq. of the Mississippi Statutes. The followiructions Mississippi Durable Power of Attorney for Health Care This package contains (1) Information and Instruction for Mississippi Durable Power of Attorney for Health Care ; (2) Mississippi Durablet 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 Information and Instan 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 consequences arising oua 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 us ed or signed without consulting 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 intended and are not s known as an Advance Health Care Directive. The first form is the Power of Attorney for Health Care and the second form is the Living Will and Revocation. [_] These forms are provided "as is" and noMississippi Advance Health Care Directive This package contains both a Mississippi Power of Attorney for Health Care and a Mississippi Living Will & Revocation. Together these forms are also sometime Mississippi