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Minnesota ________________________________ 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 MinnesotaMinnesota 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 MinnesotaMinnesota of your medical record at your physician's office and at the hospital, home care agency, hospice, or nursing facility where you receive your care. -8- x). Give signed copies to your doctors, family, close friends, health care agent, and alternate health care agent. Make sure your doctor is willing to follow your wishes. This document should be part s Two) Print Name: ___________________________________ Address: ______________________________________ REMINDER: Keep this document with your personal papers in a safe place (not in a safe deposit boabove in (A), I must initial this box: [______________] I certify that the information in (i) through (iv) is true and correct. -7- _____________________________________________ (Signature of Witnest named as a health care agent or an alternate health care agent in this document. (iv) If I am a health care provider or an employee of a health care provider giving direct care to the person listed me) acknowledged his/her signature on this document or acknowledged that he/she authorized the person signing this document to sign on his/her behalf. (ii) I am at least 18 years of age. (iii) I am no ___________________________________ Address: ______________________________________ Witness Two: (i) In my presence on ________________________ (date), ___________________________________________(na, I must initial this box: [______________] I certify that the information in (i) through (iv) is true and correct. _____________________________________________ (Signature of Witness One) Print Name: health care agent or an alternate health care agent in this document. (iv) If I am a health care provider or an employee of a health care provider giving direct care to the person listed above in (A)dged his/her signature on this document or acknowledged that he/she authorized the person signing this document to sign on his/her behalf. (ii) I am at least 18 years of age. (iii) I am not named as a provider giving direct care to me on the day I sign this document. -6- Witness One: (i) In my presence on ________________________ (date), ___________________________________________(name) acknowle___________________ (Signature of Notary) (Notary Stamp) Option 2: Two Witnesses Two witnesses mus t sign. Only one of the two witnesses can be a health care provider or an employee of a health caret he/she authorized the person signing this document to sign on his/her behalf. I am not named as a health care agent or alternate health care agent in this document. ________________________________: Notary Public In my presence on ________________________ (date), __________________________________________________________ (name) acknowledged his/her signature on this document or acknowledged tha the person who I asked to sign this document for me) __________________________________________________________________ (Printed name of the person who I asked to sign this document for me) Option 1____________________________________________ If I cannot sign my name, I can ask someone to sign this document for me. __________________________________________________________________ (Signature ofocument willingly. ___________________________________________ My Signature Date signed: ________________________________ Date of birth: _______________________________ Address: ______________________ 1) OR witnessed by two witnesses (Option 2). It must be dated when it is verified or witnessed. I am thinking clearly, I agree with everything that is written in this document, and I have made this d______________________________________________________________ PART III: MAKING THE DOCUMENT LEGAL -5- This document must be signed by me. It also must either be verified by a notary public (Option_________ Any other things: _____________________________________________________________________________ _____________________________________________________________________________ _______________at happens to my body when I die (cremation, burial): _____________________________________________________________________________ ____________________________________________________________________s of my body when I die: _____________________________________________________________________________ _____________________________________________________________________________ My wishes about wh about dying: _____________________________________________________________________________ _____________________________________________________________________________ My wishes about donating part_______________________________________________________________________ _____________________________________________________________________________ Where I would like to die and other wishes I have_______________________________________________________________ _____________________________________________________________________________ Where I would like to live to receive health care: ____________________________________________________________________ There are other things that I want or do not want for my health care, if possible: -4- Who I would like to be my doctor: ______________pain. This is how I feel about pain relief if it would affect my alertness or if it could shorten my life: _____________________________________________________________________________ _________________________________________________________ _____________________________________________________________________________ In all circumstances, my doctors will try to keep me comfortable and reduce my _______________________________________________________ If I were completely dependent on others for my care and unable to decide or speak for myself, I would want: ____________________________________________ If I were permanently unconscious and unable to decide or speak for myself, I would want: _____________________________________________________________________________ ______________________d unable to decide or speak for myself, I would want: _____________________________________________________________________________ ____________________________________________________________________for myself, I would want: _____________________________________________________________________________ _____________________________________________________________________________ If I were dying anin these situations: (Note: You can discuss general feelings, specific treatments, or leave any of them blank) If I had a reasonable chance of recovery, and were temporarily unable to decide or speak stopped heart, surgeries, dialysis, antibiotics, and blood transfusions. Most medical treatments can be tried for a while and then stopped if they do not help. I have these views about my health care mprove my medical condition or to prolong my life. Examples include artificial breathing by a machine connected to a tube in the lungs, artificial feeding or fluids through tubes, attempts to start a ___________________________ THIS IS WHAT I WANT AND DO NOT WANT FOR MY HEALTH CARE (I know I can change these choices or leave any of them blank) -3- Many medical treatments may be used to try to it how my medical condition might affect my family: ____________________ _____________________________________________________________________________ ____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ My thoughts abou___________________________________________________________ _____________________________________________________________________________ My beliefs about when life would be no longer worth living: _______________ _____________________________________________________________________________ My spiritual or religious beliefs and traditions: _______________________________________ _____________________________________________________________________ My fears about my health care: ____________________________________________________ ________________________________________________________________health care: My goals for my health care: _____________________________________________________ _____________________________________________________________________________ _______________________________ THESE ARE MY BELIEFS AND VALUES ABOUT MY HEALTH CARE (I know I can change these choices or leave any of them blank) I want you to know these things about me to help you make decisions about my ___________________________________________ -2- _____________________________________________________________________________ ________________________________________________________________________ll happen with my body when I die (burial, cremation). If I want to say anything more about my health care agent's powers or limits on the powers, I can say it here: __________________________________INITIAL the line in front of the power; then my agent WILL HAVE that power. (1) To decide whether to donate any parts of my body, including organs, tissues, and eyes, when I die. (2) To decide what wi___________________________________________ My health care agent is NOT automatically given the powers listed below in (1) and (2). If I WANT my agent to have any of the powers in (1) and (2), I must hat here: _____________________________________________________________________________ _____________________________________________________________________________ __________________________________ have to give my medical records to other people. If I DO NOT want my health care agent to have a power listed above in (A) through (D) OR if I want to LIMIT any power in (A) through (D), I MUST say tse my health care providers. (C) Choose where I live and receive care and support when those choices relate to my health care needs. (D) Review my medical records and have the same rights that I wouldtment, service, or procedures. This includes deciding whether to stop or not start health care that is keeping me or might keep me alive, and deciding about intrusive mental health treatment. (B) Chooam unable to decide or speak for myself, my health care agent has the power to: (A) Make any health care decision for me. This includes the power to give, refuse, or withdraw consent to any care, treaw my health care instructions in this document or any other instructions I have given to my agent. If I have not given health care instructions, then my agent must act in my best interest. Whenever I IF I AM UNABLE TO DECIDE OR SPEAK FOR MYSELF (I know I can change these choices) My health care agent is automatically given the powers listed below in (A) through (D). My health care agent must folloth care agent: __________________________________________ _____________________________________________________________________________ -1- THIS IS WHAT I WANT MY HEALTH CARE AGENT TO BE ABLE TO DO tionship of my alternate health care agent to me: __________________________________ Telephone number of my alternate health care agent: __________________________________ Address of my alternate healAPPOINTMENT OF ALTERNATE HEALTH CARE AGENT: If my health care agent is not reasonably available, I trust and appoint __________________________________________ to be my health care agent instead. Rela__________________________ Address of my health care agent: __________________________________________________ _____________________________________________________________________________ (OPTIONAL) ons for me. This person is called my health care agent. Relationship of my health care agent to me: __________________________________________ Telephone number of my health care agent: _______________ your agent and give your agent a copy. When I am unable to decide or speak for myself, I trust and appoint _________________________________________________________________ to make health care decisican change my agent or alternate agent at any time and I know I do not have to appoint an agent or an alternate agent) NOTE: If you appoint an agent, you should discuss this health care directive withterest if I have not made my health care wishes known. APPOINTMENT OF HEALTH CARE AGENT THIS IS WHO I WANT TO MAKE HEALTH CARE DECISIONS FOR ME IF I AM UNABLE TO DECIDE OR SPEAK FOR MYSELF (I know I for myself. My health care agent must make health care decisions for me based on instructions I provide in this document, if any, the wishes I have made known to him or her, or must act in my best in_______________________________________, understand this document allows me to name another person (called the health care agent) to make health care decisions for me if I am unable to decide or speaksed with a tax professional. [_] The purchase and use of these forms is subject to the Discla imers and Terms of Use found at findlegalforms.com -5- Health Care Directive I, ________________________it fits your particular situation. You should also consult an attorney whenever a document is negotiated with another party. Any possible tax consequences arising out of this document should be discusorms should only be a starting point for you and 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 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 state. These fon of the principal's registered domestic partnership. [_] 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 a health care power of attorney is revoked by the commencement of proceedings for dissolution, annulment, or termination of the principal's -4- marriage or commencement of proceedings for terminatie agent. Unless the principal has otherwise specified in the health care directive, the appointment by the principal of the principal's spouse or registered domestic partner as health care agent under extent the subsequent instrument is inconsistent with any prior instrument. Subd. 2. Effect of dissolution or annulment of marriage or termination of domestic partnership on appointment of health carent to revoke the health care directive in whole or in part in the presence of two witnesses who do not have to be present at the same time; or (4) executing a subsequent health care directive, to thehole or in part; (2) executing a statement, in writing and dated, expressing the principal's intent to revoke the health care directive in whole or in part; (3) verbally expressing the principal's inting the health care directive instrument or directing another in the presence of the principal to destroy the health care directive instrument, with the intent to revoke the health care directive in wth the capacity to do so may revoke a health care directive in whole or in part at any time by doing any of the following: (1) canceling, defacing, obliterating, burning, tearing, or otherwise destroyn- making capacity; or if other conditions for effectiveness otherwise specified by the principal have been met. 145C.09 Revocation of health care directive. Subdivision 1. Revocation. A principal wi the principal have been met. A health care directive is not effective for a health care decision when the principal, in the determination of the attending physician of the principal, recovers decisiopal, in the determination of the attending physician of the principal, lacks decision- making capacity to make the health care decision; or if other conditions for effectiveness otherwise specified byare to the principal. 145C.06 When effective. A health care directive is effective for a health care decision when: (1) it meets the requirements of section 145C.03, subdivision 1; and (2) the princie of a health care provider providing direct care to the principal on the date of execution. A person notarizing a health care directive may be an employee of a health care provider providing direct c the health care power of attorney. -3- (b) At least one witness to the execution of the health care directive must not be a health care provider providing direct care to the principal or an employe) A health care agent or alternate health care agent appointed in a health care power of attorney may not act as a witness or notary public for the execution of the health care directive that includes the date of execution of the health care directive or on the date the health care agent must make decisions for the principal. Subd. 3. Individuals ineligible to act as witnesses or notary public. (an the date of execution of the health care directive or on the date the health care agent must make decisions for the principal; or (2) an employee of a health care provider attending the principal onpal by blood, marriage, registered domestic partnership, or adoption, or unless the principal has otherwise specified in the health care directive: (1) a health care provider attending the principal oaking capacity is not eligible to act as the health care agent. (b) The following individuals are not eligible to act as the health care agent, unless the individual appointed is related to the princiuals ineligible to act as health care agent. (a) An individual appointed by the principal under section 145C.05, subdivision 2, paragraph (b), to make the determination of the principal's decision- mbehalf of the principal, either by a notary public or by witnesses as provided under this chapter; and (6) include a health care instruction, a health care power of attorney, or both. Subd. 2. Individther person authorized by the principal to sign on behalf of the principal; (5) contain verification of the principal's signature or the signature of the person authorized by the principal to sign on care directive (1) be in writing; (2) be dated; (3) state the principal's name; (4) be executed by a principal with capacity to do so with the signature of the principal or with the signature of ano decision-making capacity, unless otherwise specified in the health care directive. -2- 145C.03 Requirements. Subdivision 1. must: Legal sufficiency. To be legally sufficient in this state, a healthinclude a health care power of attorney to appoint a health care agent to make health care decisions for the principal when the principal, in the judgment of the principal's attending physician, lacksare directive may include one or more health care instructions to direct health care providers, others assisting with health care, family members, and a health care agent. A health care directive may in a timely manner considering the urgency of the principal's health care needs. 145C.02 Health care directive. A principal with the capacity to do so may execute a health care directive. A health c. "Principal" means an individual age 18 or older who has executed a health care directive. Subd. 9. Reasonably available. "Reasonably available" means able to be contacted and willing and able to act.755. Subd. 7a. Health care instruction. "Health care instruction" means a written statement of the principal's values, preferences, guidelines, or directions regarding health care. Subd. 8. Principalto 144.58, a nursing home licensed to serve adults under section 144A.02, a home care provider licensed under sections 144A.43 to 144A.47, or a hospice provider licensed under sections 144A.75 to 144Aproviders, including health maintenance organizations licensed under chapter 62D. Subd. 7. Health care facility. "Health care facility" means a hospital or other entity licensed under sections 144.50 y, organization, or corporation licensed, certified, or otherwise authorized or permitted by the laws of this state to administer health care directly or through an arrangement with other health care ey, or both; or a durable power of attorney for health care executed under this chapter before August 1, 1998. Subd. 6. Health care provider. "Health care provider" means a person, health care facilit Subd. 5a. Health care directive. "Health care directive" means a written instrument that complies with section 145C.03 and includes one or more health care instructions, a health care power of attornns on these matters relate to the health care needs of the person. Subd. 5. Health care decision. "Health care decision" means the consent, refusal of consent, or withdrawal of consent to health care.5 prohibiting assisted suicide. "Health care" also includes the establishment of a person's abode -1- within or without the state and personal security safeguards for a person, to the extent decisioealth care" includes the provision of nutrition or hydration parenterally or through intubation but does not include any treatment, service, or procedure that violates the provisions of section 609.21decisions for the principal. Subd. 4. Health care. "Health care" means any care, treatment, service, or procedure to maintain, diagnose, or otherwise affect a person's physical or mental condition. "Hre agent" may also be referred to as "agent." Subd. 3. Health care power of attorney. "Health care power of attorney" means an instrument appointing one or more health care agents to make health care e agent. "Health care agent" means an individual age 18 or older who is appointed by a principal in a health care power of attorney to make health care decisions on behalf of the principal. "Health casion- making capacity" means the ability to understand the significant benefits, risks, and alternatives to proposed health care and to make and communicate a health care decision. Subd. 2. Health car health care provider, or any other person is not acting in good faith if the person violates the provisions of section 609.215 prohibiting assisted suicide. Subd. 1b. Decision- making capacity. "Decinsidering the principal's overall general health condition and prognosis and the principal's personal values to the extent known. Notwithstanding any instruction of the principal, a health care agent,n or revocation of the information expressed. If these sources of information do not provide adequate guidance to the actor, "act in good faith" means acting in the best interests of the principal, cogarding intrusive mental health treatment executed under section 253B.03, subdivision 6d, or information otherwise made known by the principal, unless the actor has actual knowledge of the modificatioSubd. 1a. Act in good faith. "Act in good faith" means to act consistently with a legally sufficient health care directive of the principal, a living will executed under chapter 145B, a declaration reating to the Health Care Directive (Power of Attorney for Health Care and Living Will) Form. 145C.01 Definitions. Subdivision 1. Applicability. The definitions in this section apply to this chapter. ttorney for Health Care Form. This Minnesota Power of Attorney for Health Care is based in part on Minnesota Statutes Chapter 145C.16. The following are useful excerpts from the Minnesota Statutes relInformation and Instructions Minnesota Power of Attorney for Health Care This package contains (1) Information and Instruction for Minnesota Power of Attorney for Health Care; (2) Minnesota Power of A MinnesotaMinnesota oxy 6 __________________________________ Address: ______________________________________ Reminder: · · Keep the signed original with your personal papers. Give signed copies to your doctors, family, and pr___ (Witness Signature) Print Name: ___________________________________ Address: ______________________________________ _____________________________________________ (Witness Signature) Print Name: _ proxy by the living will, and to the best of my knowledge, I am not entitled to any part of the estate of the Declarant under a will or by operation of law. __________________________________________ration of law, and neither of whom is your proxy.) I certify that the Declarant voluntarily signed this living will in my presence and that the Declarant is personally known to me. I am not named as a_____ ___________________________________ NOTARY PUBLIC 5 OR (Sign and date here in the presence of two adult witnesses, neither of whom is entitled to any part of your estate under a will or by ope. _________________________________ ) ) ) Subscribed, sworn to, and acknowledged before me by ________________________________ (name of Declarant) on this ___________ day of ________________, _______________________________ (Pursuant to §145B.03 (2)(a): A living will is effective only if it is signed by the Declarant and two witnesses or a notary public Living will.) STATE OF MINNESOTA COUNTY OF ther form to donate some or all of my organs when I die. [________] I do not wish to become an organ donor upon my death. DATE: ____________________________________________ SIGNED: ___________________ for donation. Therefore, it is in my best interests to inform my next of kin about my decision ahead of time and ask them to honor my request. I (have) (have not) agreed in another document or on ano_____________________________________________________ _________________________________________________________________________ I understand that, upon my death, my next of kin may be asked permissionicially on a breathing machine, (i.e., artificial ventilation), so that my organs can be removed. Limitations or special wishes: (If any) _________________________________________ ____________________s your wish: [________] In the event of my death, I would like to donate my organs. I understand that to become an organ donor, I must be declared brain dead. My organ function may be maintained artifto the proxy or my health care provider. 4 (9) Organ Donation After Death. (If you wish, you may indicate whether you want to be an organ donor upon your death.) Initial the statement which expressenship: (If any) ________________________________ I understand that I have the right to revoke the appointment of the persons named above to act on my behalf at any time by communicating that decision horize the following person to do so: Name: ____________________________________________ Address: __________________________________________ Phone Number: _____________________________________ Relatioip: (If any) ________________________________ If the person I have named above refuses or is unable or unavailable to act on my behalf, or if I revoke that person's authority to act as my proxy, I autrdian or conservator of my person. Name: ____________________________________________ Address: __________________________________________ Phone Number: _____________________________________ Relationsh proxy has full power and authority to make health care decisions for me. If a guardian or conservator of the person is to be appointed for me, I nominate my proxy named in this document to act as guaructions, I designate the following person(s) to act on my behalf consistently with my instructions, if any, as stated in this document. Unless I write instructions that limit my proxy's authority, my You may also name a proxy without including specific instructions regarding your care. If you name a proxy, you should discuss your wishes with that person.) If I become unable to communicate my inst_____________________________________________________________________ (8) Proxy Designation. (If you wish, you may name someone to see that your wishes are carried out, but you do not have to do this.___________________________________ _____________________________________________________________________________ _____________________________________________________________________________ ________eligious beliefs, philosophy, or other personal values that you feel are important. You may also state preferences concerning the location of your care.) 3 ___________________________________________________________________________ _____________________________________________________________________________ (7) Thoughts I feel are relevant to my instructions. (You may, but need not, give your r_____________________________________________________________________________ _____________________________________________________________________________ ____________________________________________dministered sustenance should I have a terminal condition (you may indicate whether you wish to receive food and fluids given to you in some other way than by mouth if you have a terminal condition): if I reject artificially administered sustenance, then I may die of dehydration or malnutrition rather than from my illness or injury. The following are my feelings and wishes regarding artificially a______________________ _____________________________________________________________________________ _____________________________________________________________________________ (6) I recognize that treatment that you do not want if you have a terminal condition): _____________________________________________________________________________ ____________________________________________________________________________ (5) I particularly do not want the following kinds of life-sustaining treatment if I am diagnosed to have a terminal condition (you may list the specific types of life-sustaining_________________________________________________________________ _____________________________________________________________________________ ________________________________________________________ may list the specific types of life-sustaining treatment that you do want if you have a terminal condition): _____________________________________________________________________________ _______________________________________________________________________________ (4) I particularly want to have the following kinds of life-sustaining treatment if I am diagnosed to have a terminal condition (you_____________________________ _____________________________________________________________________________ _____________________________________________________________________________ 2 ________________________________________ (3) I particularly do not want the following (you may list specific treatment you do not want in certain circumstances): __________________________________________________________________________________________________________________________ _____________________________________________________________________________ _______________________________________________ave all appropriate health care that will help in the following ways (you may give instructions for care you do want): _____________________________________________________________________________ __________________ _____________________________________________________________________________ _____________________________________________________________________________ (2) I particularly want to hte the circumstances under which this living will applies): _____________________________________________________________________________ ______________________________________________________________edical and health care decisions for myself as long as I am able to do so and to revoke this living will at any time. (1) The following are my feelings and wishes regarding my health care (you may stahealth care providers are legally bound to act consistently with my wishes, within the limits of reasonable medical practice and other applicable law. I also understand that I have the right to make millfully and voluntarily make this statement as a directive to be followed if I am in a terminal condition and become unable to participate in decisions regarding my health care. I understand that my or a notary public. 1 TO MY FAMILY, DOCTORS, AND ALL THOSE CONCERNED WITH MY CARE: I, ____________________________________, born on ____________________ (birthdate), being an adult of sound mind, wou do not understand, you should ask for professional help to have it explained to you. Pursuant to §145B.03 (2)(a): A living will is effective only if it is signed by the Declarant and two witnesses medical records and to consent to their disclosure for purposes related to your health care or insurance unless you limit this right in this document. (e) If there is anything in this document that y continues to reflect your preferences. You may amend or revoke the living will at any time by notifying your health care providers. (d) Your named proxy has the same right as you have to examine your instructions or tell you that they are unwilling to do so. (c) This document will remain valid and in effect until and unless you amend or revoke it. Review this document periodically to make sure itr wishes. If the proxy does not know your wishes, the proxy has the duty to act in your best interests. If you do not name a proxy, your health care providers have a duty to act consistently with yourtate where you want or do not want to receive any treatment. (b) If you name a proxy in this document and that person agrees to serve as your proxy, that person has a duty to act consistently with youn you are in a terminal condition and cannot do so. This document may include what kind of treatment you want or do not want and under what circumstances you want these decisions to be made. You may snt, you should know these important facts: (a) This document gives your health care providers or your designated proxy the power and guidance to make health care decisions according to your wishes whechase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Health Care Living Will Notice: This is an important legal document. Before signing this documeom 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 purfrom 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 frsuitability 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 and n of the former spouse as a proxy to make health care decisions for the Declarant. [_] These forms are provided "as is" and no implied or express warranties have been made or are provided as to their ressly provides otherwise, if after executing a living will the Information & Instructions ­ Page 3 Declarant's marriage is dissolved or annulled, the dissolution or annulment revokes any designatio provider shall note the revocation as part of the Declarant's medical record. Subd. 2. Effect of marriage dissolution or annulment on designation of proxy. Unless a living will under this chapter exprant's physical or mental condition. A revocation is effective when the Declarant communicates it to the attending physician or other health care provider. The attending physician or other health careion 525.544. 145B.09 Revocation. Subdivision 1. General. A living will under this chapter may be revoked in whole or in part at any time and in any manner by the Declarant, without regard to the Declal." Subd. 3. Guardian or conservator. Except as otherwise provided in the living will, designation of a proxy is considered a nomination of a guardian or conservator of the person for purposes of sectlaration on the document: "I certify that the Declarant voluntarily signed this living will in my presence and that the Declarant is personally known to me. I am not named as a proxy by the living wilDeclarant under a will then existing or by operation of law. Neither of the witnesses nor the notary may be named as a proxy in the living will. Each witness shall substantially make the following decly unable to sign the document, one of the witnesses shall sign the document at the Declarant's direction. (d) Neither of the witnesses can be someone who is entitled to any part of the estate of the he withholding or withdrawing of artificially administered nutrition or hydration. (c) The living will may be communicated to and then transcribed by one of the witnesses. If the Declarant is physicalion artificially shall be made pursuant to section 145B.13. However, the mere existence of a living will or appointment of a proxy does not, by itself, create a presumption that the Declarant wanted tutrition and hydration, the living will shall be enforceable as to all other preferences or instructions regarding health care, and a decision to administer, withhold, or withdraw nutrition and hydratt if the Declarant is unable to make health care decisions and the living will becomes operative. If the living will does not state the Declarant's preferences regarding artificial administration of ntion of nutrition and hydration; or (2) that the Declarant wishes the proxy, if any, to make decisions regarding the administering of artificially administered nutrition and hydration for the Declaranthe Declarant and two witnesses or a notary public. (b) A living will must state: (1) the Declarant's preferences regarding whether the Declarant wishes to receive or not receive artificial administralth care decisions on behalf of the Declarant, or both. Information & Instructions ­ Page 2 Subd. 2. Requirements for executing a living will. (a) A living will is effective only if it is signed by nsent to or refusal of any health care, treatment, service, procedure, or placement. A living will may include preferences or instructions regarding health care, the designation of a proxy to make heaing will. Subdivision 1. Scope. A competent adult may make a living will of preferences or instructions regarding health care. These preferences or instructions may include, but are not limited to, cobd. 8. Terminal condition. "Terminal condition" means an incurable or irreversible condition for which the administration of medical treatment will serve only to prolong the dying process. 145B.03 Livaws of this state to administer health care directly or through an arrangement with other health care providers. Subd. 7. HMO. "HMO" means an organization licensed under sections 62D.01 to 62D.30. Su to 144A.49. Subd. 6. Health care provider. "Health care provider" means a person, health care facility, organization, or corporation licensed, certified, or otherwise authorized or permitted by the lility" means a hospital or other entity licensed under sections 144.50 to 144.58; a nursing home licensed to serve adults under section 144A.02; or a home care provider licensed under sections 144A.43. Subd. 4. Health care decision. "Health care decision" means a decision to begin, continue, increase, limit, discontinue, or not begin any health care. Subd. 5. Health care facility. "Health care fac3. Subd. 3. Health care. "Health care" means care, treatment, services, or procedures to maintain, diagnose, or treat an individual's physical condition when the individual is in a terminal conditionng Wills. 145B.02 Definitions. Subdivision 1. Applicability. The definitions in this section apply to this chapter. Subd. 2. Living will. "Living will" means a writing made according to section 145B.0innesota Health Care Living Will is based on Minnesota Statutes Chapter 145B.02 et. Seq. For your convenience, we have included useful excerpts from the Minnesota Statutes relating to Health Care LiviInformation and Instructions Minnesota Health Care Living Will This package contains (1) Information and Instruction for Minnesota Health Care Living Will; (2) Minnesota Health Care Living Will This M MinnesotaMinnesota _________________ 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 MinnesotaMinnesota ________ 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 MinnesotaMinnesota _____________ 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 Minnesota