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North Dakota ________________________________ 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 North DakotaNorth Dakota 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 DakotaNorth Dakota ___ Address: ______________________________________ 4 ox: [_____]. I certify that the information in (1) through (3) is true and correct _____________________________________________ (Signature of Witness Two) Print Name: ________________________________ least eighteen years of age. (3) If I am a health care or long-term care provider or an employee of a health care or long-term care provider giving direct care to the declarant, I must initial this bme of declarant) acknowledged the declarant's signature on this document or acknowledged that the declarant directed the person signing this document to sign on the declarant's behalf. 3 (2) I am atSignature of Witness One) Print Name: ___________________________________ Address: ______________________________________ Witness Two: (1) In my presence on _________ (date), _____________________ (nae provider giving direct care to the declarant, I must initial this box: [_____]. I certify that the information in (1) through (3) is true and correct. _____________________________________________ ( signing this document to sign on the declarant's behalf. (2) I am at least eighteen years of age. (3) If I am a health care or long-term care provider or an employee of a health care or long-term carss One: (1) In my presence on _________ (date), _____________________ (name of declarant) acknowledged the declarant's signature on this document or acknowledged that the declarant directed the persong this document to sign on the declarant's behalf. ______________________________ (Signature of Notary Public) My commission expires __________________________ , 20__. i. Option 2: Two Witnesses Witneon _______________ (date), ____________________________________(name of declarant) acknowledged the declarant's signature on this document or acknowledged that the declarant directed the person signin____________________________________________________________ (Declarant's Signature) City, County, and State of Residence _______________________________ 2 h. Option 1: Notary Public In my presence y signing this declaration, I am at least eighteen years of age, and I am emotionally and mentally competent to make this declaration. g. I understand that I may revoke this declaration at any time. _gnosed as pregnant and that diagnosis is known to my physician, this declaration is not effective during the course of my pregnancy. f. I understand the importance of this declaration, I am voluntarilsician determines that I cannot physically assimilate nutrition or hydration or that nutrition or hydration would be physically harmful or would cause unreasonable physical pain. e. If I have been dia the administration of nutrition and hydration, I understand that if I make no statement about nutrition or hydration, my attending physician may withhold or withdraw nutrition or hydration if the phyor hydration would only prolong the process of my dying. (3) [________] I do not wish to receive hydration. (4) [________] I make no statement concerning the administration of hydration. d. Concerningwish to receive hydration. (2) [________] I wish to receive hydration unless I cannot physically assimilate hydration, hydration would be physically harmful or would cause unreasonable physical pain, t concerning the administration of nutrition. c. I have made the following decision concerning the administration of hydration when my death is imminent (initial only one statement): (1) [________] I sically harmful or would cause unreasonable physical pain, or nutrition would only prolong the process of my dying. (3) [________] I do not wish to receive nutrition. (4) [________] I make no statemenmminent (initial only one statement): (1) [________] I wish to receive nutrition. 1 (2) [________] I wish to receive nutrition unless I cannot physically assimilate nutrition, nutrition would be phycal treatment be provided. (3) [________] I make no statement concerning life-prolonging treatment. b. I have made the following decision concerning the administration of nutrition when my death is ig treatment, will result in my imminent death. It is my intention that this declaration be honored by my family and physicians as the final expression of my legal right to direct that medical or surgiment, which could extend my life, be used if two physicians certify that I am in a terminal condition that is an incurable or irreversible condition which, without the administration of life-prolonginthe final expression of my legal right to refuse medical or surgical treatment and that they accept the consequences of that refusal, which is death. (2) [________] I direct that life-prolonging treatfe-prolonging treatment would serve only to artificially prolong the process of my dying; and (c) I am not pregnant. It is my intention that this declaration be honored by my family and physicians as I am in a terminal condition that is an incurable or irreversible condition which, without the administration of life-prolonging treatment, will result in my imminent death; (b) The application of li-prolonging treatment (initial 1, 2, or 3): (1) [________] I direct that life-prolonging treatment be withheld or withdrawn and that I be permitted to die naturally if two physicians certify that: (a)the Disclaimers and Terms of Use found at findlegalforms.com Living Will DECLARATION I declare on ____________________________(month, day, year): a. I have made the following decision concerning lifehen dealing with estate planning matters. Any possible tax consequences arising out of this document should be discussed with a tax professional. [_] The purchase and use of these forms is subject to y be a starting point for you and should not be used or signed without consulting an attorney first to make sure it fits your particular situation. Advice from a local attorney is always recommended wto their legal effect or completeness. [_]These forms are not intended and are not a substitute for legal and/or tax advice. Laws vary from time to time and from state to state. These forms should onlpart of the declarant's medical record. [_] These forms are provided "as is" and no implied or express warranties have been made or are provided as to their suitability for any specific purpose or as ocation is effective upon communication to the attending physician or other health care provider by the declarant. 3. The attending physician or other health care provider shall make the revocation a Physical cancellation or destruction of the declaration by the declarant or another in the declarant's presence and at the declarant's direction; or c. An oral expression of intent to revoke. 2. A rev3-06.4-05. Revocation of declaration. 1. A declaration may be revoked at any time and in any manner by the declarant, provided the declarant is competent, including by: a. A signed, dated writing; b. eight by the physician in determining the intent of the incompetent declarant. A declaration made under section 23-06.4-03 does not apply to emergency treatment performed in a prehospital situation. 2o use, withhold, or withdraw life-prolonging treatment but is presumptive evidence of the declarant's desires concerning the use, withholding, or withdrawal of such treatment and must be given great w to be in a terminal condition and no longer able to make decisions regarding administration of life-prolonging treatment. A declaration made under section 23-06.4-03 does not obligate the physician t6.4-04. When declaration operative. A declaration becomes operative when it is communicated to the attending physician, and the declarant is determined by the attending physician and another physicianof the declaration shall make it a part of the declarant's medical record and, if unwilling to comply with the declaration, promptly so advise the declarant. Information & Instructions ­ Page 3 23-0is chapter. The invalidity of any additional specific directives does not affect the validity of the declaration. (see form below) 3. A physician or other health care provider who is furnished a copy m is a preferred form, but not a required form, by which a person may execute a declaration. The declaration may include additional specific directives. Another form may be used if it complies with tharant at the time of the execution of the declaration; d. Directly financially responsible for the declarant's medical care; or e. Attending physicians of the declarant. 2. The following statutory fornt under any will of the declarant or codicil to the will or deed, existing by operation of law or otherwise, at the time of the declaration; c. Claimants against any portion of the estate of the declf execution. The notary public or any witness may not be: a. The declarant's spouse or related to the declarant by blood, marriage, or adoption; b. Entitled to any portion of the estate of the declarae execution of the declaration must not be a health care provider providing direct care to the declarant or an employee of the health care provider providing direct care to the declarant on the date ore at least eighteen years of age. A person notarizing the declaration may be an employee of a health care or long-term care provider providing direct care to the declarant. At least one witness to thon, and contain verification of the declarant's signature or the signature of the person directed by the declarant to sign on behalf of the declarant, either by notary public or by two witnesses who adeclaration governing the use, withholding, or withdrawal of life-prolonging treatment, nutrition, and hydration. The declaration must be signed by the declarant, or another at the declarant's directihat will not result in imminent death. 23-06.4-03. Declaration relating to use of life-prolonging treatment. 1. An individual of sound mind and eighteen or more years of age may execute at any time a n, in imminent death. The term does not include any form of senility, Alzheimer's disease, mental retardation, mental illness, or chronic mental or physical impairment, including comatose conditions tnal condition. 7. "Terminal condition" means an incurable or irreversible condition that, without the administration of life-prolonging treatment, will result, in the opinion of the attending physiciatient eighteen or more years of age who has executed a declaration and who has been determined by the attending physician and another physician who has personally examined the patient to be in a termiprehospital situation. 5. "Physician" means an individual licensed to practice medicine in this state pursuant to chapter 43-17. Information & Instructions ­ Page 2 6. "Qualified patient" means a pae nutrition and hydration or the performance of any medical procedure necessary to provide comfort care or alleviate pain; or medical procedures, treatment, or intervention performed in an emergency, to prolong the process of dying and where, in the judgment of the attending physician, death will occur whether or not the treatment is utilized. The term does not include the provision of appropriaty course of business or practice of a profession. 4. "Life-prolonging treatment" means any medical procedure, treatment, or intervention that, when administered to a qualified patient, will serve onlyts of subsection 1 of section 23-06.4-03. 3. "Health care provider" means a person who is licensed, certified, or otherwise authorized by the law of this state to administer health care in the ordinarires: 1. "Attending physician" means the physician who has primary responsibility for the treatment and care of the patient. 2. "Declaration" means a writing executed in accordance with the requiremenicide or permit any affirmative or deliberate act or omission to end life other than to permit the natural process of dying. 23-06.4-02. Definitions. In this chapter, unless the context otherwise requaged between each person and the person's family, the physician, and other health care providers. This chapter does not condone, authorize, approve, or permit mercy killing, euthanasia, or assisted sumedical care, including the decision to have medical or surgical means or procedures calculated to prolong the adult's life provided, withheld, or withdrawn. Communication about such matters is encour CHAPTER 23-06.4 (UNIFORM RIGHTS OF TERMINALLY ILL ACT) 23-06.4-01. Legislative intent. Every competent adult has the right and the responsibility to control the decisions relating to the adult's own based on Title 23 Chapter 23-06.4 Section 23-06.4-01 et. Seq. of the North Dakota Code. For your convenience, we have included useful excerpts from the North Dakota Statutes relating to Living Wills.Information and Instructions North Dakota Living Will This package contains (1) Information and Instruction for North Dakota Living Will; (2) North Dakota Living Will. This North Dakota Living Will is North DakotaNorth Dakota ______________________________ (Signature of alternate agent/date) -6- o withdraw when the principal is incapable of making the principal's health care decisions, I must notify the principal's physician. ___________________________________ (Signature of agent/date) _____the principal may revoke this power of attorney at any time in any manner. If I choose to withdraw during the time the principal is competent, I must notify the principal of my decision. If I choose t health care decisions for the principal only if the principal becomes incapable. I understand that I must act in good faith in exercising my authority under this power of attorney. I understand that nt for health care decisions. I understand I have a duty to act consistently with the desires of the principal as expressed in this appointment. I understand that this document gives me authority over______________________ (Signature of Witness Two) ____________________________________ (Address) 10. ACCEPTANCE OF APPOINTMENT OF POWER OF ATTORNEY. I accept this appointment and agree to serve as ager or an employee of a health care provider giving direct care to the declarant, I must initial this box: [______]. I certify that the information in (1) through (3) is true and correct. ______________this document or acknowledged that the declarant directed the person signing this document to sign on the declarant's behalf. (2) I am at least eighteen years of age. (3) If I am a health care provide ____________________________________ (Address) Witness Two: (1) In my presence on _________ (date), ____________________________________ (name of declarant) acknowledged the declarant's signature on ct care to the declarant, I must initial this box: [______]. I certify that the information in (1) through (3) is true and correct. -5- ____________________________________ (Signature of Witness One)ted the person signing this document to sign on the declarant's behalf. (2) I am at least eighteen years of age. (3) If I am a health care provider or an employee of a health care provider giving dires One: (1) In my presence on _________ (date), ____________________________________ (name of declarant) acknowledged the declarant's signature on this document or acknowledged that the declarant direc signing this document to sign on the declarant's behalf. _________________________ (Signature of Notary Public) My commission expires __________________________ , 20__. Option 2: Two Witnesses Witnes: Notary Public In my presence on __________ (date), ________________ (name of declarant) acknowledged the declarant's signature on this document or acknowledged that the declarant directed the person marriage, or adoption; 4. A person entitled to inherit any part of your estate upon your death; or 5. A person who has, at the time of executing this document, any claim against your estate. Option 1oviding you with direct care. None of the following may be used as a notary or witness: 1. A person you designate as your agent or alternate agent; 2. Your spouse; 3. A person related to you by blood,t least one witness to the execution of the document must not be a health care or long-term care provider providing you with direct care or an employee of the health care or long-term care provider prument must be (1) notarized or (2) witnessed by two qualified adult witnesses. The person notarizing this document may be an employee of a health care or long-term care provider providing your care. AANY ADDITIONAL PAGES TO THIS FORM, YOU MUST DATE AND SIGN EACH OF THE ADDITIONAL PAGES AT THE SAME TIME YOU DATE AND SIGN THIS POWER OF ATTORNEY.) -4- NOTARY PUBLIC OR STATEMENT OF WITNESSES This doc(You sign here) (THIS POWER OF ATTORNEY WILL NOT BE VALID UNLESS IT IS NOTARIZED OR SIGNED BY TWO QUALIFIED WITNESSES WHO ARE PRESENT WHEN YOU SIGN OR ACKNOWLEDGE YOUR SIGNATURE. IF YOU HAVE ATTACHED o this Statutory Form Durable Power of Attorney For Health Care on _____________ (date) at _____________________ (city) ______________________ (state) ________________________________________________ te agent.) 9. PRIOR DESIGNATIONS REVOKED. I revoke any prior durable power of attorney for health care. DATE AND SIGNATURE OF PRINCIPAL (YOU MUST DATE AND SIGN THIS POWER OF ATTORNEY) I sign my name tAlternate Agent: _______________________________________________________ _________________________________________________________________ (Insert name, address, and telephone number of second alterna___________________________________________________ __________________________________________________________________ (Insert name, address, and telephone number of first alternate agent.) b. Second point the following persons to serve as my agent to make health care decisions for me as authorized in this document, such persons to serve in the order listed below: a. First Alternate Agent: _______r loses the mental capacity to make health care decisions for me, or if I revoke that person's appointment or authority to act as my agent to make health care decisions for me, then I designate and apnot you are capable of designating another agent.) If the person designated as my agent in paragraph 1 is not available or becomes ineligible to act as my agent to make a health care decision for me oble or ineligible to act as your agent. If the agent you designated is your spouse, he or she becomes ineligible to act as your agent if your marriage is dissolved. Your agent may withdraw whether or ernate agents but you may do so. Any alternate agent you designate will be able to make the same health care decisions as the agent you designated in paragraph 1, above, in the event that agent is una____________________________ (Fill in this space ONLY if you want the authority of your agent to end on a specific date.) 8. DESIGNATION OF ALTERNATE AGENTS. (You are not required to designate any altsician. 7. DURATION. (Unless you specify a shorter period in the space below, this power of attorney will exist until it is revoked.) -3- This durable power of attorney for health care expires on ___: a. Documents titled or purporting to be a "Refusal to Permit Treatment" and "Leaving Hospital Against Medical Advice". b. Any necessary waiver or release from liability required by a hospital or phyRELEASES. Where necessary to implement the health care decisions that my agent is authorized by this document to make, my agent has the power and authority to execute on my behalf all of the following(If you want to limit the authority of your agent to receive and disclose information relating to your health, you must state the limitations in paragraph 4 above.) 6. SIGNING DOCUMENTS, WAIVERS, AND uding medical and hospital records. b. Execute on my behalf any releases or other documents that may be required in order to obtain this information. c. Consent to the disclosure of this information. ions in this document, my agent has the power and authority to do all of the following: a. Request, review, and receive any information, verbal or written, regarding my physical or mental health, incl so pursuant to North Dakota Century Code chapter 23-06.2, the Uniform Anatomical Gift Act. 5. INSPECTION AND DISCLOSURE OF INFORMATION RELATING TO MY PHYSICAL OR MENTAL HEALTH. Subject to any limitattement. If you attach additional pages, you must date and sign EACH of the additional pages at the same time you date and sign this document.) If you wish to make a gift of any bodily organ you may do____________________________________________ ______________________________________________________________________________ (You may attach additional pages if you need more space to complete your staement of desires, special provisions, and limitations regarding health care decisions: ______________________________________________________________________________ _________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ b. Additional state special provisions and limitations stated below: a. Statement of desires concerning life-prolonging care, treatment, services, and procedures: _______________________________________________________re limits provided by law.) -2- In exercising the authority under this durable power of attorney for health care, my agent shall act consistently with my desires as stated below and is subject to thhis document, you should state the limits in the space below. If you do not state any limits, your agent will have broad powers to make health care decisions for you, except to the extent that there ame other means. If there are any types of treatment that you do not want to be used, you should state them in the space below. If you want to limit in any other way the authority given your agent by tn also include a statement of your desires concerning other matters relating to your health care. You can also make your desires known to your agent by discussing your desires with your agent or by sostate your desires in the space provided below. You should consider whether you want to include a statement of your desires concerning life-prolonging care, treatment, services, and procedures. You came paragraph.) 4. STATEMENT OF DESIRES, SPECIAL PROVISIONS, AND LIMITATIONS. (Your agent must make health care decisions that are consistent with your known desires. You can, but are not required to, the authority of your agent to make health care decisions for you, you can state the limitations in paragraph 4 below. You can indicate your desires by including a statement of your desires in the sathis document or otherwise made known to my agent, including my desires concerning obtaining or refusing or withdrawing life-prolonging care, treatment, services, and procedures. (If you want to limitnt that I could make such decisions for myself if I had the capacity to do so. In exercising this authority, my agent shall make health care decisions that are consistent with my desires as stated in care. 3. GENERAL STATEMENT OF AUTHORITY GRANTED. Subject to any limitations in this document, I hereby grant to my agent full power and authority to make health care decisions for me to the same exten, diagnose, or treat an individual's physical or mental condition. 2. CREATION OF DURABLE POWER OF ATTORNEY FOR HEALTH CARE. By this document I intend to create a durable power of attorney for healthhorized in this document. For the purposes of this document, "health care decision" means consent, refusal of consent, or withdrawal of consent to any care, treatment, service, or procedure to maintaire provider, an operator of a long-term care facility, or a nonrelative employee of an operator of a long-term care facility) as my attorney in fact (agent) to make health care decisions for me as autl only as your agent to make health care decisions for you. None of the following may be designated as your agent: your treating health care provider, a nonrelative employee of your treating health cado hereby designate and appoint: __________________________________________________ _______________________________________________________ (insert name, address, and telephone number of one individuaoctor an executed copy of this document. 1. DESIGNATION OF HEALTH CARE AGENT. I, __________________________________ ____________________________________________________ (insert your name and address) your health care. Either keep this document where it is immediately available to your agent and alternate agents, if any, or give each of them an executed copy of this document. You should give your dthis document that you do not understand, you should ask a lawyer to explain it to you. Your agent may need this document immediately in case of an emergency that requires a -1- decision concerning u should carefully read and follow the witnessing procedure described at the end of this form. This document will not be valid unless you comply with the witnessing procedure. If there is anything in the right to examine your medical records and to consent to their disclosure unless you limit this right in this document. This document revokes any prior durable power of attorney for health care. Yoou have the right to revoke the authority of your agent by notifying your agent or your treating doctor, hospital, or other health care provider orally or in writing of the revocation. Your agent has oes anything that is clearly contrary to your best interest. Unless you specify a specific period, this power will exist until you revoke it. Your agent's power and authority ceases upon your death. Yn take away the power of your agent to make health care decisions for you if your agent authorizes anything that is illegal; acts contrary to your known desires; or where your desires are not known, d is subject to any statement of your desires and any limitation that you include in this document. You may state in this document any types of treatment that you do not desire. In addition, a court cafuse to consent to, or to withdraw consent for any care, treatment, service, or procedure to maintain, diagnose, or treat a physical or mental condition if you are unable to do so yourself. This powerdical and other health care decisions for yourself so long as you can give informed consent with respect to the particular decision. This document gives your agent authority to request, consent to, re this document gives your agent the power to consent to your doctor not giving treatment or stopping treatment necessary to keep you alive. Notwithstanding this document, you have the right to make mehe power to make health care decisions for you. Your agent must act consistently with your desires as stated in this document or otherwise made known. Except as you otherwise specify in this document,these important facts: You must be at least eighteen years of age for this document to be legally valid and binding. This document gives the person you designate as your agent (the attorney in fact) tney For Health Care WARNING TO PERSON EXECUTING THIS DOCUMENT This is an important legal document that is authorized by the general laws of this state. Before executing this document, you should know uld be discussed with a tax professional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com -4- Statutory Form Durable Power Of Attorto make sure 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 shotate. These forms 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 any specific purpose or as to their legal effect or completeness. [_]These forms are not intended and are not a substitute for legal and/or tax advice. Laws vary from time to time and from state to sdo not preclude application of any other penalties provided by law. [_] These forms are provided "as is" and no implied or express warranties have been made or are provided as to their suitability forters, forges, conceals, or destroys a power of attorney or willfully alters or forges a revocation of a power of attorney is guilty of a class A misdemeanor. 3. The penalties provided in this section a withholding or withdrawal of life-sustaining procedures which hastens the death of the principal is guilty of a class C felony. 2. A person who, without authorization of the principal, willfully al Penalties. 1. A person who, without authorization of the principal, willfully alters or forges a power of attorney or willfully conceals or destroys a revocation with the intent and effect of causing form may be used if it complies with this chapter. 23-06.5-17. Statutory form of durable power of attorney. The statutory form of durable power of attorney is as follows (see form below): 23-06.5-18.ired form, by which a person may execute a durable power of attorney for health care pursuant to this chapter. It is known as "the statutory form of durable power of attorney for health care". Anotherre of such medical information. 23-06.5-16. Use of statutory form. The statutory form of durable power of attorney described in section 23-06.5-17 may be used and is the preferred form, but not a requental health, including medical and hospital records; -3- 2. Execute any releases or other documents which may be required in order to obtain such medical information; and 3. Consent to the disclosual, an agent whose authority is in effect may for the purpose of making health care decisions: 1. Request, review, and receive any information, oral or written, regarding the principal's physical or mrced spouse as the principal's agent. 23-06.5-08. Inspection and disclosure of medical information. Subject to any limitations set forth in the durable power of attorney for health care by the principding physician, and staff responsible for the principal's care of the revocation. 3. If the spouse is the principal's agent, the divorce of the principal and spouse revokes the appointment of the divoho is informed of or provided with a revocation of a durable power of attorney for health care shall immediately record the revocation in the principal's medical record and notify the agent, the attena specific intent to revoke the power; or b. By execution by the principal of a subsequent durable power of attorney for health care. 2. A principal's health care or long-term care services provider wwer of attorney for health care is revoked: a. By notification by the principal to the agent or a health care or long-term care services provider orally, or in writing, or by any other act evidencing t may withdraw by giving notice to the attending physician. The attending physician shall cause the withdrawal to be recorded in the principal's medical record. 23-06.5-07. Revocation. 1. A durable poncipal at such time as the principal becomes incapable. Until the principal becomes incapable, the agent may withdraw by giving notice to the principal. After the principal becomes incapable, the agenfective, the agent must accept the appointment in writing. Subject to the right of the agent to withdraw, the acceptance creates a duty for the agent to make health care decisions on behalf of the pri be signed by the principal's name being written by some other person in the principal's presence and at the principal's express direction. 23-06.5-06. Acceptance of appointment - Withdrawal. To be ef financially responsible for the principal's medical care, or the attending physician of the principal. If the principal is physically unable to sign, the durable power of attorney for health care maye death of the principal under a will or deed in existence or by operation of law, any other person who has, at the time of execution, any claims against the estate of the principal, a person directlyhe time of execution, the agent, the principal's spouse or heir, a person related to the principal by blood, marriage, or adoption, a person entitled to any part of the estate of the principal upon threct care to the principal or an employee of a health care or long-term care provider providing direct care to the principal on the date of execution. The notary public or any witness may not be, at ta health care or long-term care provider providing direct care to the principal. At least one witness to the execution of the document must not be a health care or long-term care provider providing dind that signature must be verified by a notary public or at least two or more subscribing witnesses who are at least eighteen years of age. A person notarizing -2- the document may be an employee of e principal who is an employee of the principal's long-term care services provider. 23-06.5-05. Execution and witnesses. The durable power of attorney for health care must be signed by the principal apal's health care provider; 2. A nonrelative of the principal who is an employee of the principal's health care provider; 3. The principal's long-term care services provider; or 4. A nonrelative of thure is first approved by court order. 23-06.5-04. Restrictions on who can act as agent. A person may not exercise the authority of agent while serving in one of the following capacities: 1. The princialth facility or state institution for a period of more than forty-five days without a mental health proceeding or other court order, or to psychosurgery, abortion, or sterilization, unless the procedable efforts to inform the principal of any proposed treatment, or of any proposal to withdraw or withhold treatment. 5. Nothing in this chapter permits an agent to consent to admission to a mental hecity to make health care decisions, as certified in writing by the principal's attending physician and filed in the principal's medical record. 4. The principal's attending physician shall make reasonin accordance with the agent's assessment of the principal's best interests. 3. Under a durable power of attorney for health care, the agent's authority is in effect only when the principal lacks capaoral beliefs, as stated orally, or as contained in the durable power of attorney for health care or in a declaration executed pursuant to chapter 23-06.4; or b. If the principal's wishes are unknown, ation with the attending physician and other health care providers, the agent shall make health care decisions: a. In accordance with the agent's knowledge of the principal's wishes and religious or mncipal in the durable power of attorney for health care, the agent has the authority to make any and all health care decisions on the principal's behalf that the principal could make. 2. After consultas executed a durable power of attorney for health care. -1- 23-06.5-03. Scope and duration of authority. 1. Subject to the provisions of this chapter and any express limitations set forth by the priiness or professional practice. 7. "Long-term care facility" or "long-term care services provider" means a long-term care facility as defined in section 50-10.1-01. 8. "Principal" means an adult who hHealth care provider" means an individual or facility licensed, certified, or otherwise authorized or permitted by law to administer health care, for profit or otherwise, in the ordinary course of busonsent to, refusal to consent to, withdrawal of consent to, or request for any care, treatment, service, or procedure to maintain, diagnose, or treat an individual's physical or mental condition. 6. "orney for health care" means a document delegating to an agent the authority to make health care decisions executed in accordance with the provisions of this chapter. 5. "Health care decision" means c and appreciate the nature and consequences of a health care decision, including the significant benefits and harms of and reasonable alternatives to any proposed health care. 4. "Durable power of atte physician, selected by or assigned to a patient, who has primary responsibility for the treatment and care of the patient. 3. "Capacity to make health care decisions" means the ability to understand context otherwise requires: 1. "Agent" means an adult to whom authority to make health care decisions is delegated under a durable power of attorney for health care. 2. "Attending physician" means thze, or approve mercy killing, or permit an affirmative or deliberate act or omission to end life, other than to allow the natural process of dying. 23-06.5-02. Definitions. In this chapter, unless thein control over their own medical care during periods of incapacity through the prior designation of an individual to make health care decisions on their behalf. This chapter does not condone, authoril excerpts from the North Dakota Statutes relating to the North Dakota Power of Attorney for Health Care Form. 23-06.5-01. Statement of purpose. The purpose of this chapter is to enable adults to retaower of Attorney for Health Care Form. This North Dakota Power of Attorney for Health Care is based Title 23 Chapter 23-06.5 Section 23-06.5-01 of the on North Dakota Statutes. The following are usefuInformation and Instructions North Dakota Power of Attorney for Health Care This package contains (1) Information and Instruction for North Dakota Power of Attorney for Health Care; (2) North Dakota P North DakotaNorth Dakota _________________ 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 DakotaNorth Dakota ________ 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 DakotaNorth Dakota _____________ 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 Dakota