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North Carolina fication. _________________________________ Signature of person taking acknowledgment (Notary Public) _________________________________ Name typed, printed, or stamped -5- before me this _____ day of ____________________, ______ by __________________________ (name of Principal), who is personally known to me or who has produced ________________________________ as identi_____ City: __________________________________ State: ___________________________________ State of NORTH CAROLINA ) ) ss County of ________________________ ) The foregoing instrument was acknowledged ________________________ City: __________________________________ State: ___________________________________ Witness Signature: ___________________________________ Name: __________________________________________ (date), at _______________________ (city), North Carolina. ________________________________ Signature of Principal Witness Signature: ___________________________________ Name: ___________ood faith and/or willful misconduct, while acting under the authority of this Power of Attorney. I may revoke this Power of Attorney at any time by providing written notice to my Agent. Signed on ____n, shall be held harmless. -4- Agent shall not be liable for losses resulting from judgment errors made in good faith. However, Agent will be liable for breach of fiduciary duty, failure to act in gce on this power of attorney. If this Durable Power of Attorney is terminated by operation of law, any person relying in good faith on the authority of this document, without notice of such terminationot effective as to a third party until the third party has actual knowledge of the revocation. I agree to indemnify the third party for any claims that arise against the third party because of relian Agent; and/or (c) my assets to be subject to a general power of appointment by my Agent. Any third party who receives a copy of this document may act under it. Revocation of the power of attorney is limited to the extent necessary to prevent (a) my income to be taxable to my Agent; (b) my Agent to have any rights or ownership with respect to any life insurance policies I may own on the life of myreasons for the use or issuance of this power-ofattorney or as to the disposition of any proceeds paid to my Agent based on this document. The powers granted to my Agent by this power-of-attorney are der applicable law, then the remaining unaffected parts of the document shall still remain in full force and effect and not be affected by any partial invalidity. No person needs to inquire as to the ts, acts or powers are not intended to restrict or limit the definition or scope of powers granted herein in any manner. If any part of this document is held to be invalid, illegal or unenforceable unprovide an accounting for all funds handled and all acts performed as my Agent. This Power of Attorney shall be construed as broadly as a General Power of Attorney. The listing of specific terms, righ also be entitled to reasonable compensation for any services provided as my Agent If so requested by myself or any authorized personal representative or fiduciary acting on my behalf, my Agent shall licensed medical doctor. My Agent shall be entitled to reimbursement of all reasonable expenses incurred as a result of carrying out any provision of this Power of Attorney. If desired, my Agent shallty" shall mean a lack of capacity to receive and evaluate information effectively, to communicate decisions, and/or to manage my financial resources and affairs properly, as certified in writing by a This Power of Attorney shall not terminate on my subsequent disability, incapacity or lack of mental competence, except as provided by any applicable statute. As used herein, "disability" or "incapaciuent disability or incapacity as certified in writing by a licensed medical doctor. The rights, powers, and authority of this document shall remain in full force and effect thereafter until my death. esult is that the disclaimed assets pass directly or indirectly to my Agent or my Agent's estate. This Durable Power of Attorney and all rights and powers therein shall become effective upon my subseqt be transferred or distributed to me from any other person, estate, trust, or other entity, as may be appropriate. However, Agent may not disclaim assets, to -3- which I would be entitled, if the ry assets to the trustee of any revocable trust created by me, if such trust exists at the time of such transfer. 17. To disclaim any interest (subject to other provisions of this document), which migho discharge any of my Agent's legal obligations, including any obligations of support which my Agent may owe to others, excluding those whom I am legally obligated to support. 16. To transfer any of mmy Agent's estate, (b) exercise any powers of appointment I may hold in favor of my Agent, my Agent's estate, my Agent's creditors, or the creditors of my Agent's estate, or (c) use any of my assets trized by this document, (a) gift, appoint, assign or designate any of my assets, interests or rights, directly or indirectly, to my Agent, my Agent's estate, my Agent's creditors, or the creditors of x annual exclusion amount in any one calendar year, and this annual right shall be non-cumulative and shall lapse at the end of each calendar year. However, my Agent may not, unless specifically authofts to Minors Act or the Uniform Transfers To Minors Act. Any gifts made shall be limited to gifts that qualify for the federal gift tax annual exclusion, shall not exceed in value the federal gift taecessary, to file any state and federal gift tax returns and documents. Gifts to minors may be made to the minor directly or parent, guardian or close friend of the minor or pursuant to the Uniform Gitable contributions of my real, personal, tangible or intangible property, to such persons or organizations without regard to whether such gifts are a part of my estate planning or otherwise, and if n or provide information to and from any agency, including governmental agencies, relating to tax matters and to negotiate, compromise or settle any matter with such agency. 15. To make gifts and chariuments with any federal, state, local or other governmental body, including, but not limited to, federal, state, local or other income and tax returns and necessary and/or related documents; to obtains may be appropriate, including but not limited to, attorneys, accountants, investment professionals, brokers and real estate agents. 14. To prepare, or cause to be prepared, sign, and/or file any docs. 12. To maintain and/or operate any business that I currently own or have an interest in or may own or have an interest in, in the future. 13. To employ any professional and/or business assistance a, remove, keep or otherwise dispose of the contents. 11. To exercise any and all rights, including proxy rights, with respect to stocks, bonds, debentures, commodities, options or any other investments. -2- 10. To have access to any safe deposit box, vault or other storage area owned or leased by me alone or in conjunction with any other person, including access to their contents, and to examinem, corporation or political entity; to perform any act necessary to deposit, negotiate, sell or transfer any note, security, or draft of the United States of America, including U.S. Treasury Securitieting or endorsing any checks or other instruments, obtaining bank statements, passbooks, drafts, warrants, money orders, certificates, cashier checks, cash or vouchers payable to me by any person, firth financial institutions; to conduct any business with any banking or financial institution with respect to any of my accounts, including, but not limited to, making deposits and withdrawals, negotia accounts, including, but not limited to, checking accounts, savings accounts, certificates of deposit, investment accounts, brokerage accounts, retirement plan accounts, and other similar accounts wi social security benefits), and to appoint anyone, including my Agent, to act as my "Representative Payee" for the purpose of receiving Social Security benefits. 9. To open, maintain and/or close banklications, provide information, and perform any other reasonable request by any government or its agencies in connection with governmental benefits (including but not limited to, medical, military andyments I receive from any annuity, pension, retirement benefits, retirement plans, insurance benefits and government program including, but not limited to, Social Security and Medicare; to prepare appnce upon my life or the life of any other appropriate person and to make any elections and disclaimers under such policies. 8. To receive, deposit, hold, demand, deal with and/or sue to recover all panies which may become due and owing to me by reason of such transaction. 7. To apply for, purchase, maintain and/or deal with insurance and annuity contracts, insurance policies, including life insuraor encumber any homestead that I now own or may own in the future; the right to remove tenants and to recover possession; and the right to ask for, demand, sue for, collect, recover and receive all mor asset whatsoever, tangible or intangible (now owned or acquired in the future by me) and to execute any necessary document, instrument or deed for such transactions. This includes the right to sell e, improve, repair, exchange, invest, reinvest and in any other manner (on such terms and at prices my Agent may deem proper) deal with all, any part or any interest in any real or personal property oe in the future, owned by, due, owing payable, or belonging to, me or in which I have or may hereafter acquire any interest, to have, or use. 6. To maintain, manage, insure, lease, rent, sell, mortgag drafts, causes of action, bequests, deposits, notes, interests, dividends, certificates of deposit, any and all documents of title and demands whatsoever, whether agreed to or disputed, now due or du, against me or asserted on my behalf against any other person or entity. -1- 5. To receive, hold, possess and/or invest any and all sums of money, accounts, debts, bonds, commercial papers, checks,ind and nature as may be. 3. To request, ask, demand, sue and take any and all legal steps necessary to recover and collect any amount or debt owed to me. 4. To adjust, compromise and settle any claims, proofs of loss, evidences of debts, releases, and satisfaction of mortgages, lien, judgments, security agreements and other debts and obligations and such other instruments in writing of whatever kxies, warrants, commercial papers, withdrawal and deposit slips, certificates of deposit of, or investments with or through banks, savings and loan, brokers, mutual fund companies or other institutionants, conveyances, deeds, options, trust deeds, security agreements, leases, mortgages, notes, insurance policies, receipts, title documents, checks, drafts, letters of credit, stock certificates, pro any written agreement and document necessary to enter into any such contract and/or agreement, including but not limited to applications, assignments, bills of sale or lading, bonds, contracts, coveno conduct, engage in, and transact any and all lawful business of whatever kind or nature, on my behalf and in my name. 2. To enter into binding contracts on my behalf and to sign, endorse and executetute or substitutes, shall lawfully do or cause to be done by virtue of this power of attorney and the rights hereby granted. My Agent's powers and authority shall include, but not be limited to: 1. T thing, business, property, real or personal, tangible or intangible, or matter whatsoever as I could do if personally present. I hereby ratify and confirm all acts that my Agent, or my Agent's substiave full power and authority to perform any act, power, duty, legal right or obligation whatsoever that I now have or may later acquire in connection with or relating to any person, item, transaction,intaining an address at: _____________________________________________________ as my alternate or successor Agent, as necessary, to serve with the same powers, rights and discretions. My Agent shall h____________ my true and lawful attorney-in-fact for me and in my name, and in my behalf. If the above named Agent is unable to serve for any reason, I appoint _____________________________________ mass at _______________________________________________ do hereby make and appoint ________________________________________ ("Agent") maintaining an address at: _________________________________________ies of an agent. -3- NORTH CAROLINA DURABLE POWER OF ATTORNEY Effective upon Disability KNOW ALL PERSONS BY THESE PRESENTS: I, ____________________________________ ("Principal") maintaining an addre decisions for you. You may revoke this power of attorney if you later wish to do so. AGENT: By accepting or acting under the appointment, the agent assumes the fiduciary and other legal responsibilittorney document, is legally binding upon you. If you have any questions about these powers, obtain competent legal advice. This document does not authorize anyone to make medical and other health-carer to handle business and legal matters on your behalf, including the power to sell, mortgage or dispose of your property. Any such action undertaken by your agent, within the scope of this power of atowers granted by this power of attorney document are broad and sweeping. Before signing this document, consider its consequences. You ("principal") are providing another person ("agent") with the poweion that is not state specific. Whenever appropriate, the instructions included with the forms packages offered for sale, generally include state specific instructions. -2- CAUTION! PRINCIPAL: The Pif the Agent will deal with any real estate in Florida. Please note that this information is not intended as and is not a substitute for legal advice. Furthermore, this information is general informato be recorded as a public record, if necessary. Although, some states don't require that a Durable Power of Attorney be witnessed, it is always a very good idea to do so. Two witnesses are necessary, t will be dealing with any real property. Notarization will make it more difficult for any third party to challenge the validity of the Power of Attorney and will allow the Durable Power of Attorney the event the original Agent is unable to serve or continue to serve as the Agent. A Durable Power of Attorney should always be notarized, even if your state does not require it, especially if the Agenme. Since this Durable Power of Attorney takes effect only after the Principal becomes disabled or incompetent, an alternate Agent can be designated, at the time this Power of Attorney is signed, in t is especially important if the Principal is incapacitated when the Power of Attorney goes into effect, or the Agent undertakes the acts. The Principal can revoke a Durable Power of Attorney at any tiney is a "powerful" instrument and should be granted with care. Any action undertaken by the Agent, within the scope of the Power of Attorney document, will be legally binding upon the Principal. This to mean "lawyer". The person acting as the attorney-in-fact for the Principal does not need to be a lawyer. Almost anyone can be appointed an attorney-in-fact by a power of attorney. A Power of Attorher behalf, even if the Principal later becomes incapacitated. This particular Form becomes effective upon the disability or incapacity of the Principal. Note that the word "attorney" is not used here A Durable Power of Attorney allows a natural "mentally competent " person (called the "Principal" or "Principal") to authorize someone else (called the "Agent" or "AttorneyIn-Fact") to act on his or another party. [_] The purchase and use of these forms, is subject to the Disclaimers and Terms of Use found at findlegalforms.com -1- Information Durable Power of Attorney Effective upon Disability legal advice. These forms should only be a starting point for you and should not be used without consulting with an attorney first. An Attorney should be consulted before negotiating a document with ower of Attorney must be filed with the office of registrar of deeds to be valid. Filing is not necessary if Principal is not incompetent. [_] These forms are not intended and are not a substitute foro serve or continue to serve as the Agent. This section can be removed, deleted (and initialed) or the words "no one" can be entered. [_] In North Carolina, if the Principal becomes incompetent, the Ps the power to handle business and legal matters on the Principal's behalf. [_] This document offers the option of nominating an alternate Agent in the event that the first choice as Agent is unable tfact) as to the tasks the Agent should complete. The Grantor should also be very careful in the selection of the Agent. The powers granted by this document are very broad and sweeping, as the Agent hapal should keep the original document, as well as a copy. The Agent should have access to the original document as needed. [_] The Principal should be careful in instructing the Agent (or attorney-in-ealing with any real estate in Florida. The witnesses should be adults. Generally, anyone related by blood or marriage to the Principal, the Agent or the Notary should not be a witness. [_] The Princid as a public record, if necessary. [_] Although not always required, it is always a good idea to also have two witnesses sign the Power of Attorney. Two witnesses are necessary if the Agent will be dility of the Principal. [_] The Principal (i.e. the person granting the Power of Attorney) should sign the document before a Notary. Notarization will allow the Durable Power of Attorney to be recordety; (2) Information for Durable Power of Attorney Effective upon Disability; (3) Durable Power of Attorney Effective upon Disability [_] This Durable Power of Attorney becomes effective upon the DisabInstructions & Checklist North Carolina Durable Power of Attorney Effective upon Disability [_] This package contains (1) Instructions & Checklist for Durable Power of Attorney Effective upon Disabili North CarolinaNorth Carolina 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 North CarolinaNorth Carolina is power of attorney, and to your physician and family members.) Source: findlegalforms.com 7 _. ___________________________________ Notary Public My Commission Expires: _______________________________ (A copy of this form should be given to your health care agent and any alternate named in th, and (iv) they did not have a claim against him/her. I further certify that I am satisfied as to the genuineness and due execution of the instrument. This the __________ day of _______________, 20___him/her, nor an employee of an attending physician, nor an employee of a health facility in which he/she was a patient, nor an employee of a nursing home or any group-care home in which he/she residedn of his/her estate upon his/her death under any will or codicil thereto then existing or under the Intestate Succession Act as it provided at that time, and (iii) they were not a physician attending essed the signing (i) they were not related within the third degree to him/her or his/her spouse, and (ii) they did not know nor have a reasonable expectation that they would be entitled to any portioared before me and swore that they witnessed _________________________ sign the attached health care power of attorney, believing him/her to be of sound mind; and also swore that at the time they witnand voluntarily made and executed it as his/her free act and deed for the purposes expressed in it. I further certify that ____________________________ and ___________________________, witnesses, appe_____________ appeared before me and swore to me and to the witnesses in my presence that this Source: findlegalforms.com 6 instrument is a health care power of attorney, and that he/she willingly NORTH CAROLINA COUNTY OF _______________________ CERTIFICATE I, _________________________________, a Notary Public for _________________ County, North Carolina, hereby certify that __________________ do not nave any claim against the principal. Witness: ______________________________________ Date: __________________ Witness: ______________________________________ Date: __________________ STATE OFding physician, nor an employee of the health facility in which the principal is a patient, nor an employee of a nursing home or any group care home where the principal resides. I further state that I an heir under the Intestate Succession Act, if the principal died on this date without a will. I also state that I am not the principal's attending physician, nor an employee of the principal's attence, and that I am not related to the principal by blood or marriage, and I would not be entitled to any portion of the estate of the principal under any existing will or codicil of the principal or as_______ (SEAL) 9. Signatures of Witnesses. I hereby state that the Principal, ____________________________________, being of sound mind, signed the foregoing health care power of attorney in my presenlly informed as to the contents of this document, and understand the full import of this grant of powers to my health care agent. Signature of Principal__________________________________ Date ________ of conduct authorized by this health care power of attorney may interpose this document as a defense. 8. Signature of principal. By signing here, I indicate that I am mentally alert and competent, funal purposes, nor shall it be considered unprofessional conduct or as lack of professional competence. Any person, institution, or facility against whom criminal or civil liability is asserted becausey acting in good faith in reliance on the authority of my health care agent pursuant to this health care power of attorney shall be considered suicide, nor the cause of my death for any civil or crimions of my health care agent pursuant to this document, except for willful misconduct or gross negligence. D. No act or omission of my health care agent, or of any other person, institution, or facilitand forever discharged by me, my estate, my heirs, successors, and assigns and personal representatives from all liability and from all claims or demands of all kinds arising out of the acts or omissihave any authority over my property or financial affairs. Source: findlegalforms.com 5 C. My health care agent and my health care agent's estate, heirs, successors, and assigns are hereby released he exercise of these powers; provided, however, that except as shall be necessary in order to exercise the powers described in this document relating to my health care, my health care agent shall not ocument that may be necessary, desirable, convenient, or proper in order to exercise and carry out any of the powers described in this document and to incur reasonable costs on my behalf incident to td others. 7. Miscellaneous provisions. A. I revoke any prior health care power of attorney. B. My health care agent shall be entitled to sign, execute, deliver, and acknowledge any contract or other dirs, successors, assigns, and personal representatives. The authority of my health care agent pursuant to this power of attorney shall be superior to and binding upon my family, relatives, friends, anr of attorney are done with my consent and shall have the same validity and effect as if I were present and exercised the powers myself, and shall inure to the benefit of and bind me, my estate, my hehorized by me and with the same force and effect as if I were personally present, competent, and acting on my own behalf. All acts performed in good faith by my health care agent pursuant to this powe agent by this document may be exercised by my health care agent alone, and my health care agent's signature or act under the authority granted in this document may be accepted by persons as fully autlth care agent shall be liable to me, my estate, my heirs, successors, assigns, or personal representatives, for actions or omissions by my health care agent. B. The powers conferred on my health careuardian shall act consistently with G.S. 35A-1201(a)(5). 6. Reliance of third parties on health care agent. A. No person who relies in good faith upon the authority of or any representations by my heat becomes necessary for a court to appoint a guardian of my person, I nominate my health care agent acting under this document to be the guardian of my person, to serve without bond or security. The g______________________ ________________________________________________________________________ ________________________________________________________________________ 5. Guardianship provision. If ither you have executed an advance instruction for mental health treatment.): ________________________________________________________________________ __________________________________________________ause your health care agent's decisions about decisions must be consistent with any Source: findlegalforms.com 4 statements you have expressed in an advance instruction, you should indicate here whe which you may use to state your instructions regarding mental health treatment in the event you lack sufficient understanding or capacity to make or communicate mental health treatment decisions. Bec care power of attorney may incorporate or be combined with an advance instruction for mental health treatment, executed in accordance with Part 2 of Article 3 of Chapter 122C of the General Statutes,______________________________ ________________________________________________________________________ ________________________________________________________________________ C. (Notice: This healthand retention in a health care facility for mental health treatment, or instructions to refuse any specific types of treatment that are unacceptable to you): __________________________________________alth treatment decisions, your own instructions regarding the administration or withholding of psychotropic medications and electroconvulsive treatment (ECT), instructions regarding your admission to gent is subject to the following special provisions and limitations. (Here you may include any specific limitations you deem appropriate such as: limiting the grant of authority to make only mental he________________ ________________________________________________________________________ B. In exercising the authority to make mental health decisions on my behalf, the authority of my health care a______________________________________________________________________ ________________________________________________________________________ ________________________________________________________tment should be withheld or discontinued, or instructions to refuse any specific types of treatment that are inconsistent with your religious beliefs, or unacceptable to you for any other reason.): __ care agent is subject to the following special provisions and limitations (Here you may include any specific limitations you deem appropriate such as: your own definition of when life-sustaining treaIf you wish to limit the scope of your health care agent's powers, you may do so in this section.) A. In exercising the authority to make health care decisions on my behalf, the authority of my healthThe above grant of power is intended to be as broad as possible so that your health care agent will have authority to make any decisions you could make to obtain or terminate any type of health care. I. To take any lawful actions that may be necessary to carry out these decisions, including the granting of releases of liability to medical providers. 4. Special provisions and limitations. (Notice: ve to make a disposition of any part or all of my body for medical purposes, to donate my organs, to authorize an autopsy, and to direct the disposition of my remains. Source: findlegalforms.com 3 MY LIFE NOT BE PROLONGED BY LIFE-SUSTAINING PROCEDURES IF I AM TERMINALLY ILL, PERMANENTLY IN A COMA, SUFFER SEVERE DEMENTIA, OR AM IN A PERSISTENT VEGETATIVE STATE. H. To exercise any right I may haother forms of medical treatment which sustain, restore or supplant vital bodily functions. Life-sustaining procedures do not include care necessary to provide comfort or alleviate pain. I DESIRE THATedures are those forms of medical care that only serve to artificially prolong the dying process and may include mechanical ventilation, dialysis, antibiotics, artificial nutrition and hydration, and of life-sustaining procedures when and if my physician determines that I am terminally ill, permanently in a coma, suffer severe dementia, or am in a persistent vegetative state. Life-sustaining procthorization of a licensed physician, dentist, or podiatrist. This authorization specifically includes the power to consent to measures for relief of pain. G. To authorize the withholding or withdrawalment". F. To give consent for, to withdraw consent for, or to withhold consent for, X ray, anesthesia, medication, surgery, and all other diagnostic and treatment procedures ordered by or under the au or treatment of mental illness. E. To consent to and authorize the administration of medications for mental health treatment and electroconvulsive treatment (ECT) commonly referred to as "shock treatand authorize my admission to and discharge from a hospital, nursing or convalescent home, or other institution. D. To consent to and authorize my admission to and retention in a facility for the care mental health, including, but not limited to, medical and hospital records, and to consent to the disclosure of this information. B. To employ or discharge my health care providers. C. To consent to including mental health treatment decisions, on my behalf, including, but not limited to, the following: A. To request, review, and receive any information, verbal or written, regarding my physical or_________ 3. General statement of authority granted. Except as indicated in section 4 below, I hereby grant to my health care agent named above full power and authority to make health care decisions, ________________________________ ________________________________________________________________________ Source: findlegalforms.com 2 _______________________________________________________________termination before the authority granted to the health care agent becomes effective.): ________________________________________________________________________ ________________________________________ding physician or eligible psychologist, or any other physician or eligible psychologist. You may also name two or more physicians or eligible psychologists, if desired, both of whom must make this desions related to mental health treatment, this determination shall be made by the following physician or eligible psychologist. (You may include here a designation of your choice, including your attenr communicate decisions relating to my health care and will continue in effect during my incapacity, until my death. This determination shall be made by the following physician or physicians. For deci revocation, the authority granted in this document shall become effective when and if the physician or physicians designated below determine that I lack sufficient understanding or capacity to make ohealth care power of attorney may be revoked by you at any time in any manner by which you are able to communicate your intent to revoke to your health care agent and your attending physician.) Absent_____________ Each successor health care agent designated shall be vested with the same power and duties as if originally named as my health care agent. 2. Effectiveness of appointment. (Notice: This _____________________________________________________ Home Address: ___________________________________________________________ Home Telephone Number ____________________ Work Telephone Number _________________________ Home Address: ___________________________________________________________ Home Telephone Number _____________________ Work Telephone Number _____________________ B. Name: __________as my agent, then I appoint the following persons (each to act alone and successively, in the order named), to serve in that capacity: (Optional) A. Name: _____________________________________________e health care decisions for me as authorized in this document. Source: findlegalforms.com 1 If the person named as my health care agent is not reasonably available or is unable or unwilling to act ______ Work Telephone Number __________________ as my health care attorney-in-fact (herein referred to as my "health care agent") to act for me and in my name (in any way I could act in person) to makreby appoint Name: _____________________________________________________________________ Home Address: ______________________________________________________________ Home Telephone Number ____________ different form of power of attorney for health care that meets the statutory requirements.) 1. Designation of health care agent. I, __________________________________________, being of sound mind, heursuant to North Carolina law. However, use of this form is an optional and nonexclusive method for creating a health care power of attorney and North Carolina law does not bar the use of any other orning procedures, mental health treatment, and other health care decisions with your health care agent. Use of this form in the creation of a health care power of attorney is lawful and is authorized pw the health care agent believes you would act if you were making the decision. Because the powers granted by this document are broad and sweeping, you should discuss your wishes concerning lifesustair health care agent will have to use due care to act in your best interests and in accordance with this document. For mental health treatment decisions, your health care agent will act according to hothose health care decisions for which you are unable to give informed consent. This form does not impose a duty on your health care agent to exercise granted powers, but when a power is exercised, youconsent to your doctor not giving treatment or stopping treatment necessary to keep you alive, admit you to a facility, and administer certain treatments and medications. This power exists only as to ing mental health treatment decisions, for you. Except to the extent that you express specific limitations or restrictions on the authority of your health care agent, this power includes the power to North Carolina Health Care Power of Attorney Statutory Form, G.S. 32A-25 (Notice: This document gives the person you designate your health care agent broad powers to make health care decisions, includ North CarolinaNorth Carolina or Notary Public (circle one as appropriate) for the County of ____________________________ 2 ineness and due execution of the declaration. This the ____ day of ___________, _________.(month and year) __________________________________________________ Clerk (Assistant Clerk) of Superior Court t or an employee of a nursing home or any group-care home in which the declarant resided, and (iv) they did not have a claim against the declarant. I further certify that I am satisfied as to the genus it provides at that time, and (iii) they were not a physician attending the declarant or an employee of an attending physician or an employee of a health facility in which the declarant was a patienthey would be entitled to any portion of the estate of the declarant upon the declarant's death under any will of the declarant or codicil thereto then existing or under the Intestate Succession Act ae time they witnessed the declaration (i) they were not related within the third degree to the declarant or to the declarant's spouse, and (ii) they did not know or have a reasonable expectation that s, appeared before me and swore that they witnessed ____________________________________________, declarant, sign the attached declaration, believing him to be of sound mind; and also swore that at thact and deed for the purposes expressed in it. I further certify that __________________________________________________________ and __________________________________________________________ witnesseand swore to me and to the witnesses in my presence that this instrument is his Declaration Of A Desire For A Natural Death, and that he had willingly and voluntarily made and executed it as his free rior Court or Notary Public (circle one as appropriate) for __________________ County hereby certify that __________________________________________________________, the declarant, appeared before me clerk or the assistant clerk, or a notary public may, upon proper proof, certify the declaration as follows: Certificate I, _________________________________________, Clerk (Assistant Clerk) of Supe______________ (Witness Signature) Print Name: ___________________________________ _____________________________________________ (Witness Signature) Print Name: ___________________________________ The 1 patient or an employee of a nursing home or any group-care home where the declarant resides. I further state that I do not now have any claim against the declarant. _______________________________te without a will. I also state that I am not the declarant's attending physician or an employee of the declarant's attending physician, or an employee of a health facility in which the declarant is a I would be entitled to any portion of the estate of the declarant under any existing will or codicil of the declarant or as an heir under the Intestate Succession Act if the declarant died on this da__________, being of sound mind signed the above declaration in my presence and that I am not related to the declarant by blood or marriage and that I do not know or have a reasonable expectation thatay of _______________, ________________ (month and year) __________________________________________ (Declarant's Signature) I hereby state that the declarant, _________________________________________n addition to withholding or discontinuing extraordinary means if such means are necessary, physician may withhold or discontinue either artificial nutrition or hydration, or both. This the ________ dth. _________ If my physician determines that I am in a persistent vegetative state, I authorize the following: _________ My physician may withhold or discontinue extraordinary means only. _________ Ins only. _________ In addition to withholding or discontinuing extraordinary means if such means are necessary, my physician may withhold or discontinue either artificial nutrition or hydration, or boany of the following, as desired): _________ If my condition is determined to be terminal and incurable, I authorize the following: _________ My physician may withhold or discontinue extraordinary meaunderstand that this writing authorizes a physician to withhold or discontinue extraordinary means or artificial nutrition or hydration, in accordance with my specifications set forth below: (Initial y extraordinary means or by artificial nutrition or hydration if my condition is determined to be terminal and incurable or if I am diagnosed as being in a persistent vegetative state. I am aware and Living Will Declaration Of A Desire For A Natural Death I, _________________________________________________________, being of sound mind, desire that, as specified below, my life not be prolonged bonsequences arising out of this document should be discussed with a tax professional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.comed without consulting an attorney first to make sure it fits your particular situation. Advice from a local attorney is always recommended when dealing with estate planning matters. Any possible tax ct 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 and should not be used or signprovided "as is" and no implied or express warranties have been made or are provided as to their suitability for any specific purpose or as to their legal effect or completeness. [_]These forms are noicle 3 of Chapter 32A of the General Statutes; provided, however, that the resulting form shall be signed, witnessed, and proved in accordance with the provisions of this section. [_] These forms are prior to July 1, 1979, shall continue to be valid. (j) The form provided by this section may be combined with or incorporated into a health care power of attorney form meeting the requirements of Artgainst whom criminal or civil liability is asserted because of conduct in compliance with this section may interpose this section as a defense. (i) Any certificate in the form provided by this sectionh in accordance with this section shall not be considered the cause of death for any civil or criminal purposes nor shall it be considered unprofessional conduct. Any person, institution or facility antract or for receiving any medical treatment. (h) The withholding or discontinuance of extraordinary means and/or the withholding or discontinuance of either artificial nutrition or hydration, or botor any purpose. Information & Instructions ­ Page 3 (g) No person shall be required to sign a declaration in accordance with subsection (c) as a condition for becoming insured under any insurance coysician by the declarant or by an individual acting on behalf of the declarant. (f) The execution and consummation of declarations made in accordance with subsection (c) shall not constitute suicide fy manner by which he is able to communicate his intent to revoke, without regard to his mental or physical condition. Such revocation shall become effective only upon communication to the attending phf the handwriting of the two witnesses whose testimony is unavailable, and b. Upon compliance with paragraph c of subdivision (2) above. (e)The above declaration may be revoked by the declarant, in aness and due execution of the declaration. (3) If the testimony of none of the witnesses is available, such declaration may be proved by the clerk or assistant clerk, or a notary public a. Upon proof oting of the declarant, unless he signed by his mark; or upon proof of such other circumstances as will satisfy the clerk or assistant clerk of the superior court, or a notary public as to the genuinen is available, then a. Upon the testimony of such witness, and b. Upon proof of the handwriting of the witness who is dead or whose testimony is otherwise unavailable, and c. Upon proof of the handwri . . declaration may be proved by the clerk or the assistant clerk, or a notary public in the following manner: (1) Upon the testimony of the two witnesses; or (2) If the testimony of only one witnessf superior court, or a notary public who certifies substantially as set out in subsection (d) below. (d) The following form is specifically determined to meet the requirements above: (See Below) The .the declarant resides, and (iv) do not have a claim against any portion of the estate of the declarant at the time of the declaration; and (4) Which has been proved before a clerk or assistant clerk otending physician, or an employee of the attending physician, or an employee of a health facility in which the declarant is a patient, or an employee of a nursing home or any group-care home in which y portion of the estate of the declarant upon his death under any will of the declarant or codicil thereto then existing or under the Intestate Succession Act as it then provides, (iii) are not the atd and who state that they (i) are not related within the third degree to the declarant or to the declarant's spouse, (ii) do not know or have a reasonable expectation that they would be entitled to anr discontinue the extraordinary means or artificial nutrition or hydration; and (3) Which has been signed by the declarant in the presence of two witnesses who believe the declarant to be of sound minal and incurable, or if the declarant is diagnosed as being in a persistent vegetative state; and (2) Which states that the declarant is aware that the declaration authorizes a physician to withhold o desire of the declarant that extraordinary means or artificial nutrition or hydration not be used to prolong his life if his condition is determined to be Information & Instructions ­ Page 2 termin of that declaration obtained from the Advance Health Care Directive Registry maintained by the Secretary of State pursuant to Article 21 of Chapter 130A of the General Statutes; (1) Which expresses awithheld or discontinued upon the direction and under the supervision of the attending physician. (c) The attending physician may rely upon a signed, witnessed, dated and proved declaration, or a copyondition as set out above in subdivision (b)(1) by a physician other than the attending physician; then extraordinary means or artificial nutrition or hydration, as specified by the declarant, may be nt condition is a. Terminal and incurable; or b. Repealed by Session Laws 1993, c. 553, s. 28; c. Diagnosed as a persistent vegetative state; and (2) There is confirmation of the declarant's present ceans or by artificial nutrition or hydration, and the declaration has not been revoked in accordance with subsection (e); and (1) It is determined by the attending physician that the declarant's preseion or hydration, will succumb to death within a short period of time. (b) If a person has declared, in accordance with subsection (c) below, a desire that his life not be prolonged by extraordinary mcondition whereby in the judgment of the attending physician the patient suffers from a sustained complete loss of self-aware cognition and, without the use of extraordinary means or artificial nutritvital function; (3) "Physician" means any person licensed to practice medicine under Article 1 of Chapter 90 of the laws of the State of North Carolina; (4) "Persistent vegetative state" is a medical ined as any medical procedure or intervention which in the judgment of the attending physician would serve only to postpone artificially the moment of death by sustaining, restoring, or supplanting a 90-321. Right to a natural death. (a) As used in this Article the term: (1) "Declarant" means a person who has signed a declaration in accordance with subsection (c); (2) "Extraordinary means" is def Will is based on Chapter 90 Section 90-321 et. Seq. of the North Carolina Statutes. For your convenience, we have included useful excerpts from the North Carolina Statutes relating to Living Wills. §Information and Instructions North Carolina Living Will This package contains (1) Information and Instruction for North Carolina Living Will; (2) North Carolina Living Will. This North Carolina Living North CarolinaNorth Carolina _________________ 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 North CarolinaNorth Carolina ________ 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 North CarolinaNorth Carolina _____________ 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 North Carolina