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New Hampshire ________________________________ 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 New HampshireNew Hampshire 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 New HampshireNew Hampshire ature________________________________________ Official Capacity _________________________________ 2 orn to and signed before me by _________________________________________, declarant ___________________________________, and ___________________________________, witnesses on ____________________ Signofficial authorized to administer oaths in the place of execution, who shall not also serve as a witness, and who shall complete and sign a certificate in content and form substantially as follows: Sw_____________________________ (Witness Signature) _____________________________________________ (Witness Signature) The affidavit shall be made before a notary public or justice of the peace or other other witness. 3. To the best of my knowledge, at the time of the signing the declarant was at least 18 years of age, and was of sane mind and under no constraint or undue influence. ________________ a free and voluntary act for the purposes expressed, or expressly directed another to sign for him. 2. Each witness signed at the request of the declarant, in his presence, and in the presence of the__________ We, the following witnesses, being duly sworn each declare to the notary public or justice of the peace or other official signing below as follows: 1. The declarant signed the instrument aslaration. __________________________________________ (Declarant's Signature) Print Name: ________________________________ Address: ___________________________________ _________________________________ to refuse medical or surgical treatment and accept the consequences of such refusal. 1 I understand the full import of this declaration, and I am emotionally and mentally competent to make this decility to give directions regarding the use of such life-sustaining procedures, it is my intention that this declaration shall be honored by my family and physicians as the final expression of my right______________________ ____________________________________________________________________________ ____________________________________________________________________________ In the absence of my abt. If you do not choose "yes,'' artificial nutrition and hydration will be provided and will not be removed.) Additional Instructions (optional): ______________________________________________________ave given under this section, I authorize that artificial nutrition and hydration not be started or, if started, be discontinued. (Yes) _______ (No) ______ (Circle your choice and initial beneath iide me with comfort care. I realize that situations could arise in which the only way to allow me to die would be to discontinue artificial nutrition and hydration. In carrying out any instruction I hocedures be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication, sustenance, or the performance of any medical procedure deemed necessary to provd or that I will remain in a permanently unconscious condition and where the application of life-sustaining procedures would serve only to artificially prolong the dying process, I direct that such prysicians who have personally examined me, one of whom shall be my attending physician, and the physicians have determined that my death will occur whether or not life-sustaining procedures are utilizecumstances set forth below, do hereby declare: If at any time I should have an incurable injury, disease, or illness certified to be a terminal condition or a permanently unconscious condition by 2 ph ___ day of ___ (month, year). I, _________________________________, being of sound mind, willfully and voluntarily make known my desire that my dying shall not be artificially prolonged under the cir 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 Living Will DECLARATION Declaration made this sure it fits your particular situation. Advice from a local attorney is always recommended when dealing with estate planning matters. Any possible tax consequences arising out of this document shouldnd/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 signed without consulting an attorney first to makeas to their suitability for any specific purpose or as to their legal effect or completeness. Information & Instructions ­ Page 3 [_]These forms are not intended and are not a substitute for legal aospital, no more than one witness may be the health care provider or such provider's employee. [_] These forms are provided "as is" and no implied or express warranties have been made or are provided inst the estate of the person, and shall be acknowledged pursuant to the provisions of RSA 456 or RSA 456-A. If the person making the document is a resident of a health care facility or patient in a hn's spouse, heir at law, attending physician or person acting under the direction or control of the attending physician or any other person who has at the time of the witnessing thereof any claims aga7-H:4 Execution and Witness. ­ The document set forth in RSA 137-H:3 shall be executed by the person making the same in the presence of 2 or more subscribing witnesses, none of whom shall be the persofective if the person is permanently incapable of participating in decisions about his care, and it may be, but need not be, in form and substance substantially as follows: (see form below) Section 13commonly known as a living will, directing that no lifesustaining procedures be used to prolong his life when he is in a terminal condition or is permanently unconscious. The document shall only be efenance'' means the natural ingestion of food or fluids by eating and drinking. Section 137-H:3 Living Will. ­ A person of sound mind who is 18 years of age or older may execute at any time a document invasive procedures such as but not limited to the following: nasogastric tubes; gastrostomy tubes; intravenous feeding or hydration; and hyperalimentation. It shall not include sustenance. IX. "Sustreness of self and environment, and all other indicia of consciousness are absent as determined by the attending physician and a consulting physician. VIII. "Artificial nutrition and hydration'' meansthe attending physician and a consulting physician, only postpone the moment of death. VII. "Permanently unconscious'' means a lasting condition, indefinitely and without change, in which thought, awaeans an incurable condition caused by injury, disease, or illness which is such that death is imminent and the application of life-sustaining measures would, within the reasonable medical judgment of in writing to be in a terminal condition or permanently unconscious by 2 physicians who have personally examined the patient, one of whom shall be the attending physician. VI. "Terminal condition'' mctice in the state of New Hampshire pursuant to RSA 329. V. "Qualified patient'' means a patient who has executed a declaration in accordance with this chapter and who has been diagnosed and certifiedhope of recovery from such condition and is unable to actively participate in the decision-making process. Information & Instructions ­ Page 2 IV. "Physician'' means a medical doctor licensed to prahen duly executed, contains the express direction that no life-sustaining procedures be taken when the person executing said document is in a terminal condition or is permanently unconscious, without e the administration of medication, sustenance, or the performance of any medical procedure deemed necessary to provide comfort care or to alleviate pain. III. "Living will'' means a document which, wre, in the written judgment of the attending physician and the consulting physician, the patient is in a terminal condition or is permanently unconscious. "Lifesustaining procedures'' shall not includion, which, in the written judgment of the attending physician and a consulting physician, when applied to the qualified patient, would serve only to artificially postpone the moment of death, and whend care of the patient. II. "Life-sustaining procedures'' means any medical procedure or intervention which utilizes mechanical or other artificial means to sustain, restore, or supplant a vital functntly unconscious. Section 137-H:2 Definitions - In this chapter: I. "Attending physician'' means the physician selected by or assigned to the patient who has primary responsibility for the treatment a competent person to make a written declaration instructing his physician to provide, withhold, or withdraw life-sustaining procedures in the event such person is in a terminal condition or is permaneactively in decisions about themselves, and to encourage communication between patients and their physicians, the legislature hereby declares that the laws of this state shall recognize the right of actity of the person, to control the decisions relating to the rendering of his own medical care. In order that the rights of persons may be respected even after they are no longer able to participate iving Wills. TITLE X (PUBLIC HEALTH) CHAPTER 137-H (LIVING WILLS) Section 137-H:1 Purpose and Policy. - The state of New Hampshire recognizes that a person has a right, founded in the autonomy and sanl is based on Title X Chapter 137-H Section 137-H:3 et. Seq. of the New Hampshire Revised Statutes. For your convenience, we have included useful excerpts from the New Hampshire Statutes relating to LInformation and Instructions New Hampshire Living Will This package contains (1) Information and Instruction for New Hampshire Living Will; (2) New Hampshire Living Will. This New Hampshire Living Wil New HampshireNew Hampshire __________, 20 ___, by _____________________________________ ______________________________________ Notary Public/Justice of the Peace My Commission Expires: -5- __________________________ Address: ______________________________________ -4- STATE OF NEW HAMPSHIRE COUNTY OF __________ The foregoing instrument was acknowledged before me this __________ day of tness Signature) Print Name: ___________________________________ Address: ______________________________________ _____________________________________________ (Witness Signature) Print Name: _________lth care is signed and that the principal has affirmed that he or she is aware of the nature of the document and is signing it freely and voluntarily. _____________________________________________ (Widay of ___, 20___ __________________________________________ (Signature) I declare that the principal appears to be of sound mind and free from duress at the time the durable power of attorney for hea_____________________________________________________ ______________________________________________________________________________ In witness whereof, I have hereunto signed my name this __________ ____________________________ and the following persons and institutions will have signed copies: _____________________________________________________________________________ _________________________th a disclosure statement explaining the effect of this document. I have read and understand the information contained in the disclosure statement. The original of this document will be kept at ______ act as my health care agent, I hereby appoint ____________________________________________ of ___________________________________ as alternate agent. I hereby acknowledge that I have been provided wi___________________________________________________________________ (attach additional pages as necessary) In the event the person I appoint above is unable, unwilling or unavailable, or ineligible to______________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ -3- ______________________________________________________________________________ ________________________________________________out refusing any specific types of treatment that are inconsistent with your religious beliefs or unacceptable to you for any other reason. You may leave this question blank if you desire. ___________ion and hydration.) 4. Here you may include any specific desires or limitations you deem appropriate, such as when or what life-sustaining treatment you would want used or withheld, or instructions abtreatment be withdrawn, artificial nutrition and hydration continue to be given to me. (If you fail to complete item 3, your agent will not have the power to direct the withdrawal of artificial nutritice of (a) or (b) and initial beside it): _______ (a) artificial nutrition and hydration not to be started or, if started, be discontinued, -or________ (b) although all other forms of life-sustaining (artificial nutrition and hydration). In carrying out any instructions I have given above in #1 or #2 or any instructions I may write in #4 below, I authorize my agent to direct that (circle your chochoice and initial beneath it.). (YES) _____________ (NO) ________________ 3. I realize that situations could arise in which the only way to allow me to die would be to discontinue artificial feeding) _____________ (NO) ________________ 2. Whether terminally ill or not, if I become permanently unconscious I authorize my agent to direct that life-sustaining treatment be discontinued (Circle your lth care decisions, and if I am also suffering from a terminal illness, I authorize my agent to direct that life-sustaining treatment be discontinued (Circle your choice and initial beneath it.). (YESou may indicate your agreement or disagreement with any of the following statements and give your agent power to act in those specific circumstances. 1. If I become permanently incompetent to make heacal devices, drugs to maintain blood pressure, blood transfusions, and antibiotics.) There is also a section which allows you to set forth specific directions for these or other matters. If you wish yithout which a person would die, such as but not limited to the following: cardiopulmonary resuscitation, mechanical respiration, kidney dialysis or the use of other external mechanical and technologienience in expressing your wishes, some general statements concerning the withholding or removal of life-sustaining treatment are set forth below. (Life-sustaining treatment is defined as procedures wcare shall take effect in the event I become unable to make my own health care decisions. STATEMENT OF DESIRES, SPECIAL PROVISIONS, AND LIMITATIONS REGARDING HEALTH CARE DECISIONS. -2- For your conv______________ as my agent to make any and all health care decisions for me, except to the extent I state otherwise in this document or as prohibited by law. This durable power of attorney for health ES MAY BE YOUR HEALTH OR RESIDENTIAL CARE PROVIDER OR ONE OF THEIR EMPLOYEES. POWER OF ATTORNEY I, ___________________________________, hereby appoint ___________________________ of __________________OLLOWING PERSONS MAY NOT ACT AS WITNESSES: --the person you have designated as your agent; --your spouse; --your lawful heirs or beneficiaries named in your will or a deed; ONLY ONE OF THE TWO WITNESSor you. THIS POWER OF ATTORNEY WILL NOT BE VALID UNLESS IT IS SIGNED IN THE PRESENCE OF TWO (2) OR MORE QUALIFIED WITNESSES WHO MUST BOTH BE PRESENT WHEN YOU SIGN AND ACKNOWLEDGE YOUR SIGNATURE. THE Fagent in the event that your agent is unwilling, unable, unavailable, or ineligible to act as your agent. Any alternate agent you designate will have the same authority to make health care decisions frovider orally or in writing. This document may not be changed or modified. If you want to make changes in the document you must make an entirely new one. You should consider designating an alternate u are able to do so, and treatment cannot be given to you or stopped over your objection. You have the right to revoke the authority granted to your agent by informing him or her or your health care pnt will not be liable for health care decisions made in good faith on your behalf. Even after you have signed this document, you have the right to make health care decisions for yourself as long as yohould discuss this document with your agent and your physician and give each a signed copy. You should indicate on the document itself the people and institutions who will have signed copies. Your agehealth or residential care provider; the law does not permit a person to do both at the same time. You should inform the person you appoint that you want him or her to be your health care agent. You ssician, or an -1- employee of a home health agency, hospital, nursing home, or residential care home, other than a relative), that person will have to choose between acting as your agent or as your yer to explain it to you. The person you appoint as agent should be someone you know and trust and must be at least 18 years old. If you appoint your health or residential care provider (e.g. your phy these issues and can answer your questions. You do not need a lawyer's assistance to complete this document, but if there is anything in this document that you do not understand, you should ask a lawsign it to make sure that you understand the nature and range of decisions which may be made on your behalf. If you do not have a physician, you should talk with someone else who is knowledgable about decisions about your health care as you would have had if made consistent with state law. It is important that you discuss this document with your physician or other health care providers before you ou to eat and drink normally. Your agent will be obligated to follow your instructions when making decisions on your behalf. Unless you state otherwise, your agent will have the same authority to makeof nutrition and fluids, your document must say so. Otherwise, your agent will not be able to direct that. Under no conditions will your agent be able to direct the withholding of food and drink for yeligible to be your agent. You may attach additional pages if you need more space to complete your statement. If you want to give your agent authority to withhold or withdraw the artificial providing rtification that you lack capacity, you must say so in the document and name a person to be able to certify your lack of capacity. That person may not be your agent or alternate agent or any person inegin when your doctor certifies that you lack the capacity to make health care decisions. If for moral or religious reasons you do not wish to be treated by a doctor or examined by a doctor for the ce cannot be alleviated by medication. You may state in this document any treatment you do not desire, except as stated above, or treatment you want to be sure you receive. Your agent's authority will bpregnant and if the withdrawal of that treatment is deemed likely to terminate the pregnancy unless the failure to withhold the treatment will be physically harmful to you or prolong severe pain whichithdrawing or withholding life-sustaining treatment. Your agent cannot consent or direct any of the following: commitment to a state institution, sterilization, or termination of treatment if you are therefore, can have the power to make a broad range of health care decisions for you. Your agent may consent, refuse to consent, or withdraw consent to medical treatment and may make decisions about w for you when you are no longer capable of making them yourself. "Health care'' means any treatment, service or procedure to maintain, diagnose or treat your physical or mental condition. Your agent, DOCUMENT YOU SHOULD KNOW THESE IMPORTANT FACTS: Except to the extent you state otherwise, this document gives the person you name as your agent the authority to make any and all health care decisionsound at findlegalforms.com -3- Durable Power Of Attorney For Health Care INFORMATION CONCERNING THE DURABLE POWER OF ATTORNEY FOR HEALTH CARE THIS IS AN IMPORTANT LEGAL DOCUMENT. BEFORE SIGNING THIS party. 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 the Disclaimers and Terms of Use f using or signing this document you should have an attorney review it to make sure it fits your particular situation. You should also consult an attorney whenever a document is negotiated with anothergal 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 without consulting with an attorney first. Before warranties have been made or are provided as to their suitability for any specific purpose or as to their legal effect or completeness. [_]These forms are not intended and are not a substitute for lerincipal's residential care provider. IV. A nonrelative of the principal who is an employee of the principal's residential care provider. [_] These forms are provided "as is" and no implied or expressent while serving in one of the following capacities: I. The principal's health care provider. II. A nonrelative of the principal who is an employee of the principal's health care provider. III. The py a durable power of attorney for health care shall be in substantially the following form (see form below): 137-J:4 Restrictions on Who May Act as Agent. A person may not exercise the authority of ag Form The durable power of attorney shall be in substantially the following form (see form below): 137-J:14 Durable Power of Attorney; Disclosure Statement The disclosure statement which must accompanof attorney for health care may be signed by the principal's name written by some other person in the principal's presence and at the principal's express direction. 137-J:15 Durable Power of Attorney; was -2- signed and that the principal affirmed that he was aware of the nature of the document and signed it freely and voluntarily. If the principal is physically unable to sign, the durable power ntial care provider or such provider's employee. The witness shall affirm that the principal appeared to be of sound mind and free from duress at the time the durable power of attorney for health careipal upon death of the principal under a will, trust or other testamentary instrument or deed in existence or by operation of law. No more than one such witness may be the principal's health or reside presence of 2 or more subscribing witnesses, neither of whom shall, at the time of execution, be the agent, the principal's spouse or heir, or a person entitled to any part of the estate of the princall inform the principal's health or residential care provider of such revocation. 137-J:5 Execution and Witnesses The durable power of attorney for health care shall be signed by the principal in thetion in the principal's medical record and notify the agent, the attending physician, and staff responsible for the principal's care of the revocation. An agent who becomes aware of such revocation shr of attorney. II. A principal's health or residential care provider who is informed of or provided with a revocation of a durable power of attorney for health care shall immediately record the revoca. Re-execution or re-affirmation of the durable power of attorney for health care following filing for divorce shall make effective the designation of the former spouse as agent under the durable powee spouse is the principal's agent, except when there is an alternate agent designated, in which case the designation of the spouse shall be revoked and the alternate designation shall become effectivent to revoke the power; (b) By execution by the principal of a subsequent durable power of attorney for health care; or (c) By the filing of an action for divorce of the principal and spouse, where they for health care shall be revoked: (a) By notification by the principal to the agent or to a health or residential care provider orally, or in writing, or by any other act evidencing a specific intement and live birth of the unborn child or will be physically harmful to the patient or prolong severe pain which cannot be alleviated by medication. 137-J:6 Revocation. ­ I. A durable power of attornatient's chart by the attending physician and an obstetrician who has examined the patient, such treatment or procedures will not maintain the patient in such a way as to permit the continuing develop To consent to a voluntary sterilization; or (c) To consent to withholding life-sustaining treatment from a pregnant patient, unless, to a reasonable degree of medical certainty, as certified on the pr of any proposal to withdraw or withhold treatment. V. Nothing in this chapter shall be construed to give an agent authority: -1- (a) To consent to voluntary admission to any state institution; (b)ay not be given to or withheld from the principal over the principal's objection. The principal's attending physician shall make reasonable efforts to inform the principal of any proposed treatment, othe agent. IV. Notwithstanding that a durable power of attorney for health care is in effect and irrespective of the principal's lack of capacity to make health care decisions at the time, treatment mwledged before a notary or justice of the peace, as to the lack of decisional capacity of the principal. The person so designated by the principal shall not be the agent, or a person ineligible to be ious or moral beliefs as specified in the durable power of attorney for health care, a person designated by the principal in the durable power of attorney for health care may certify in writing, acknot shall be noted in the principal's medical record. A durable power of attorney for health care may include a provision that, if the principal has no attending physician for reasons based on his religalth care decisions, as certified in writing by the principal's attending physician and filed in the principal's medical record. When and if a person regains capacity to make such decisions, such evensts and in accordance with accepted medical practice. III. Under a durable power of attorney for health care, the agent's authority shall be in effect only when the principal lacks capacity to make hecare or in a terminal care document executed pursuant to the provisions of RSA 137-H; or if the principal's wishes are unknown, in accordance with the agent's assessment of the principal's best intereent's knowledge of the principal's wishes and religious or moral beliefs, as stated orally or otherwise communicated by principal to agent, or as contained in the durable power of attorney for health ncipal's behalf that the principal could make. II. After consultation with the attending physician and other health care providers, the agent shall make health care decisions in accordance with the agchapter and any express limitations set forth by the principal in the durable power of attorney for health care, the agent shall have the authority to make any and all health care decisions on the priare useful excerpts from the New Hampshire Statutes relating to the New Hampshire Power of Attorney for Health Care Form. 137-J:2 Scope and Duration of Authority. I. Subject to the provisions of this e Power of Attorney for Health Care Form. This New Hampshire Power of Attorney for Health Care is based on Title X Chapter 137-J Section 137-J:15 et. Seq. of the New Hampshire Statutes. The following Information and Instructions New Hampshire Power of Attorney for Health Care This package contains (1) Information and Instruction for New Hampshire Power of Attorney for Health Care; (2) New Hampshir New HampshireNew Hampshire _________________ 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 New HampshireNew Hampshire ________ 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 New HampshireNew Hampshire _____________ 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 New Hampshire