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Ohio -5- ______________________ as identification. _________________________________ Signature of person taking acknowledgment (Notary Public) _________________________________ Name typed, printed, or stampeding instrument was acknowledged before me this _____ day of ____________________, ______ by __________________________ (name of Principal), who is personally known to me or who has produced __________________________________ City: __________________________________ State: ___________________________________ State of __________________________ ) ) ss County of ________________________ ) The forego_ Name: ___________________________________ City: __________________________________ State: ___________________________________ Witness Signature: ___________________________________ Name: ______________________ (date), at _______________________ (city), __________________________ (state). ________________________________ Signature of Principal Witness Signature: __________________________________od faith and/or willful misconduct, while acting under the authority of this Power of Attorney. I may revoke this Power of Attorney at any time by providing written notice to my Agent. Signed on _____, shall be held harmless. -4- Agent shall not be liable for losses resulting from judgment errors made in good faith. However, Agent will be liable for breach of fiduciary duty, failure to act in goe on this power of attorney. If this Durable Power of Attorney is terminated by operation of law, any person relying in good faith on the authority of this document, without notice of such terminationot effective as to a third party until the third party has actual knowledge of the revocation. I agree to indemnify the third party for any claims that arise against the third party because of reliancAgent; and/or (c) my assets to be subject to a general power of appointment by my Agent. Any third party who receives a copy of this document may act under it. Revocation of the power of attorney is nimited to the extent necessary to prevent (a) my income to be taxable to my Agent; (b) my Agent to have any rights or ownership with respect to any life insurance policies I may own on the life of my easons for the use or issuance of this power-ofattorney or as to the disposition of any proceeds paid to my Agent based on this document. The powers granted to my Agent by this power-of-attorney are ler applicable law, then the remaining unaffected parts of the document shall still remain in full force and effect and not be affected by any partial invalidity. No person needs to inquire as to the rs, acts or powers are not intended to restrict or limit the definition or scope of powers granted herein in any manner. If any part of this document is held to be invalid, illegal or unenforceable undrovide an accounting for all funds handled and all acts performed as my Agent. This Power of Attorney shall be construed as broadly as a General Power of Attorney. The listing of specific terms, rightalso be entitled to reasonable compensation for any services provided as my Agent If so requested by myself or any authorized personal representative or fiduciary acting on my behalf, my Agent shall ps and affairs properly. My Agent shall be entitled to reimbursement of all reasonable expenses incurred as a result of carrying out any provision of this Power of Attorney. If desired, my Agent shall e statute). As used herein, "disability" or "incapacity" shall mean a lack of capacity to receive and evaluate information effectively, to communicate decisions, and/or to manage my financial resourcein full force and effect thereafter until my death. This Power of Attorney shall not terminate on my subsequent disability, incapacity or lack of mental competence (except as provided by any applicablwer of Attorney and the rights, powers, and authority of my Agent shall become effective immediately upon execution of this instrument. The rights, powers, and authority of this document shall remain e. However, Agent may not disclaim assets, to which I would be entitled, if the result is that the disclaimed assets pass directly or indirectly to my Agent or my Agent's estate. -3- This Durable Po17. To disclaim any interest (subject to other provisions of this document), which might be transferred or distributed to me from any other person, estate, trust, or other entity, as may be appropriatthers, excluding those whom I am legally obligated to support. 16. To transfer any of my assets to the trustee of any revocable trust created by me, if such trust exists at the time of such transfer. 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 obligations, including any obligations of support which my Agent may owe to o indirectly, to my Agent, my Agent's estate, my Agent's creditors, or the creditors of my Agent's estate, (b) exercise any powers of appointment I may hold in favor of my Agent, my Agent's estate, my at the end of each calendar year. However, my Agent may not, unless specifically authorized by this document, (a) gift, appoint, assign or designate any of my assets, interests or rights, directly oror the federal gift tax annual exclusion, shall not exceed in value the federal gift tax annual exclusion amount in any one calendar year, and this annual right shall be non-cumulative and shall lapsedirectly or parent, guardian or close friend of the minor or pursuant to the Uniform Gifts to Minors Act or the Uniform Transfers To Minors Act. Any gifts made shall be limited to gifts that qualify fut regard to whether such gifts are a part of my estate planning or otherwise, and if necessary, to file any state and federal gift tax returns and documents. Gifts to minors may be made to the minor egotiate, compromise or settle any matter with such agency. 15. To make gifts and charitable contributions of my real, personal, tangible or intangible property, to such persons or organizations witholocal or other income and tax returns and necessary and/or related documents; to obtain or provide information to and from any agency, including governmental agencies, relating to tax matters and to n real estate agents. 14. To prepare, or cause to be prepared, sign, and/or file any documents with any federal, state, local or other governmental body, including, but not limited to, federal, state, interest in, in the future. 13. To employ any professional and/or business assistance as may be appropriate, including but not limited to, attorneys, accountants, investment professionals, brokers andespect to stocks, bonds, debentures, commodities, options or any other investments. -2- 12. To maintain and/or operate any business that I currently own or have an interest in or may own or have an unction with any other person, including access to their contents, and to examine, remove, keep or otherwise dispose of the contents. 11. To exercise any and all rights, including proxy rights, with r, security, or draft of the United States of America, including U.S. Treasury Securities. 10. To have access to any safe deposit box, vault or other storage area owned or leased by me alone or in conjorders, certificates, cashier checks, cash or vouchers payable to me by any person, firm, corporation or political entity; to perform any act necessary to deposit, negotiate, sell or transfer any noteof my accounts, including, but not limited to, making deposits and withdrawals, negotiating or endorsing any checks or other instruments, obtaining bank statements, passbooks, drafts, warrants, money t accounts, brokerage accounts, retirement plan accounts, and other similar accounts with financial institutions; to conduct any business with any banking or financial institution with respect to any e purpose of receiving Social Security benefits. 9. To open, maintain and/or close bank accounts, including, but not limited to, checking accounts, savings accounts, certificates of deposit, investmennection with governmental benefits (including but not limited to, medical, military and social security benefits), and to appoint anyone, including my Agent, to act as my "Representative Payee" for thent program including, but not limited to, Social Security and Medicare; to prepare applications, provide information, and perform any other reasonable request by any government or its agencies in con policies. 8. To receive, deposit, hold, demand, deal with and/or sue to recover all payments I receive from any annuity, pension, retirement benefits, retirement plans, insurance benefits and governmor deal with insurance and annuity contracts, insurance policies, including life insurance upon my life or the life of any other appropriate person and to make any elections and disclaimers under suchsession; and the right to ask for, demand, sue for, collect, recover and receive all monies which may become due and owing to me by reason of such transaction. 7. To apply for, purchase, maintain and/ry document, instrument or deed for such transactions. This includes the right to sell or encumber any homestead that I now own or may own in the future; the right to remove tenants and to recover posdeem proper) deal with all, any part or any interest in any real or personal property or asset whatsoever, tangible or intangible (now owned or acquired in the future by me) and to execute any necessay interest, to have, or use. 6. To maintain, manage, insure, lease, rent, sell, mortgage, improve, repair, exchange, invest, reinvest and in any other manner (on such terms and at prices my Agent may nts of title and demands whatsoever, whether agreed to or disputed, now due or due -1- in the future, owned by, due, owing payable, or belonging to, me or in which I have or may hereafter acquire anest any and all sums of money, accounts, debts, bonds, commercial papers, checks, drafts, causes of action, bequests, deposits, notes, interests, dividends, certificates of deposit, any and all documend collect any amount or debt owed to me. 4. To adjust, compromise and settle any claim, against me or asserted on my behalf against any other person or entity. 5. To receive, hold, possess and/or invnts and other debts and obligations and such other instruments in writing of whatever kind and nature as may be. 3. To request, ask, demand, sue and take any and all legal steps necessary to recover aor through banks, savings and loan, brokers, mutual fund companies or other institutions, proofs of loss, evidences of debts, releases, and satisfaction of mortgages, lien, judgments, security agreeme, receipts, title documents, checks, drafts, letters of credit, stock certificates, proxies, warrants, commercial papers, withdrawal and deposit slips, certificates of deposit of, or investments with limited to applications, assignments, bills of sale or lading, bonds, contracts, covenants, conveyances, deeds, options, trust deeds, security agreements, leases, mortgages, notes, insurance policies name. 2. To enter into binding contracts on my behalf and to sign, endorse and execute any written agreement and document necessary to enter into any such contract and/or agreement, including but noteby granted. My Agent's powers and authority shall include, but not be limited to: 1. To conduct, engage in, and transact any and all lawful business of whatever kind or nature, on my behalf and in mynally present. I hereby ratify and confirm all acts that my Agent, or my Agent's substitute or substitutes, shall lawfully do or cause to be done by virtue of this power of attorney and the rights here or may later acquire in connection with or relating to any person, item, transaction, thing, business, property, real or personal, tangible or intangible, or matter whatsoever as I could do if persoe and lawful attorney-in-fact for me and in my name, and in my behalf. My Agent shall have full power and authority to perform any act, power, duty, legal right or obligation whatsoever that I now hav__________________________________ do hereby make and appoint ________________________________________ ("Agent") maintaining an address at: _____________________________________________________ my truies of an agent. -3- DURABLE POWER OF ATTORNEY Effective Immediately KNOW ALL PERSONS BY THESE PRESENTS: I, ____________________________________ ("Principal") maintaining an address at _____________ decisions for you. You may revoke this power of attorney if you later wish to do so. AGENT: By accepting or acting under the appointment, the agent assumes the fiduciary and other legal responsibilittorney document, is legally binding upon you. If you have any questions about these powers, obtain competent legal advice. This document does not authorize anyone to make medical and other health-carer to handle business and legal matters on your behalf, including the power to sell, mortgage or dispose of your property. Any such action undertaken by your agent, within the scope of this power of atowers granted by this power of attorney document are broad and sweeping. Before signing this document, consider its consequences. You ("principal") are providing another person ("agent") with the poweion that is not state specific. Whenever appropriate, the instructions included with the forms packages offered for sale, generally include state specific instructions. -2- CAUTION! PRINCIPAL: The Py be witnessed, it is always a very good idea to do so. Please note that this information is not intended as and is not a substitute for legal advice. Furthermore, this information is general informat the validity of the Power of Attorney and will allow the Durable Power of Attorney to be recorded as a public record, if necessary. Although, some states don't require that a Durable Power of Attorned always be notarized, even if your state does not require it, especially if the Agent will be dealing with any real property. Notarization will make it more difficult for any third party to challengee Agent, within the scope of the Power of Attorney document, will be legally binding upon the Grantor. The Grantor can revoke a Durable Power of Attorney at any time. A Durable Power of Attorney shoulappointed an Attorney-In-Fact by a power of attorney. The Agent should be a competent adult. A Power of Attorney is a "powerful" instrument and should be granted with care. Any action undertaken by th becomes incapacitated. Note that the word "attorney" is not used here to mean "lawyer". The person acting as the Attorney-In-Fact for the Principal does not need to be a lawyer. Almost anyone can be or her behalf, even if the Principal later becomes incapacitated. This particular Form becomes effective immediately and remains in full force and effect even if the Principal (i.e. the Grantor) lateriately A Durable Power of Attorney allows a natural "mentally" competent person (called the "Principal" or "Grantor") to authorize someone else (called the "Agent" or "Attorney-InFact") to act on his ment with another party. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com. -1- Information Durable Power of Attorney Effective Immedtute for legal advice. These forms should only be a starting point for you and should not be used without consulting with an attorney first. An Attorney should be consulted before negotiating any docus granted by this document are very broad and sweeping, as the Agent has the power to handle business and legal matters on the Principal's behalf. [_] These forms are not intended and are not a substie Principal should be careful in instructing the Agent (or attorney-in-fact) as to the tasks the Agent should complete. The Grantor should also be very careful in the selection of the Agent. The poweruse or children, and the Notary should not be witnesses. [_] The Principal should keep the original document, as well as a copy. The Agent should have access to the original document as needed. [_] Thhe Durable Power of Attorney to be recorded as a public record, if necessary. [_] Two witnesses need to sign the Power of Attorney. The witnesses should be competent adults. The Agent, the Agent's spo Principal (i.e. the Grantor) becomes subsequently incapacitated. [_] The Principal (i.e. the person granting the Power of Attorney) should sign the document before a Notary. Notarization will allow t Durable Power of Attorney Effective Immediately; (3) Durable Power of Attorney Effective Immediately [_] This Durable Power of Attorney becomes effective immediately and remains effective even if theInstructions & Checklist Durable Power of Attorney Effective Immediately [_] This package contains (1) Instructions & Checklist for Durable Power of Attorney Effective Immediately; (2) Information for OhioOhio amped -5- ____________________________ as identification. _________________________________ Signature of person taking acknowledgment (Notary Public) _________________________________ Name typed, printed, or stforegoing instrument was acknowledged before me this _____ day of ____________________, ______ by __________________________ (name of Principal), who is personally known to me or who has produced ___________________________________ City: __________________________________ State: ___________________________________ State of __________________________ ) ) ss County of ________________________ ) The ________ Name: ___________________________________ City: __________________________________ State: ___________________________________ Witness Signature: ___________________________________ Name: ____n ________________ (date), at _______________________ (city), __________________________ (state). ________________________________ Signature of Principal Witness Signature: ___________________________t in good faith and/or willful misconduct, while acting under the authority of this Power of Attorney. I may revoke this Power of Attorney at any time by providing written notice to my Agent. Signed oination, shall be held harmless. -4- Agent shall not be liable for losses resulting from judgment errors made in good faith. However, Agent will be liable for breach of fiduciary duty, failure to acreliance on this power of attorney. If this Durable Power of Attorney is terminated by operation of law, any person relying in good faith on the authority of this document, without notice of such termey is not effective as to a third party until the third party has actual knowledge of the revocation. I agree to indemnify the third party for any claims that arise against the third party because of of my Agent; and/or (c) my assets to be subject to a general power of appointment by my Agent. Any third party who receives a copy of this document may act under it. Revocation of the power of attorny are limited to the extent necessary to prevent (a) my income to be taxable to my Agent; (b) my Agent to have any rights or ownership with respect to any life insurance policies I may own on the lifeo the reasons for the use or issuance of this power-ofattorney or as to the disposition of any proceeds paid to my Agent based on this document. The powers granted to my Agent by this power-of-attorneble under applicable law, then the remaining unaffected parts of the document shall still remain in full force and effect and not be affected by any partial invalidity. No person needs to inquire as t, rights, acts or powers are not intended to restrict or limit the definition or scope of powers granted herein in any manner. If any part of this document is held to be invalid, illegal or unenforceashall provide an accounting for all funds handled and all acts performed as my Agent. This Power of Attorney shall be construed as broadly as a General Power of Attorney. The listing of specific terms shall also be entitled to reasonable compensation for any services provided as my Agent If so requested by myself or any authorized personal representative or fiduciary acting on my behalf, my Agent by a licensed medical doctor. My Agent shall be entitled to reimbursement of all reasonable expenses incurred as a result of carrying out any provision of this Power of Attorney. If desired, my Agentcapacity" shall mean a lack of capacity to receive and evaluate information effectively, to communicate decisions, and/or to manage my financial resources and affairs properly, as certified in writingeath. This Power of Attorney shall not terminate on my subsequent disability, incapacity or lack of mental competence, except as provided by any applicable statute. As used herein, "disability" or "insubsequent disability or incapacity as certified in writing by a licensed medical doctor. The rights, powers, and authority of this document shall remain in full force and effect thereafter until my d the result is that the disclaimed assets pass directly or indirectly to my Agent or my Agent's estate. This Durable Power of Attorney and all rights and powers therein shall become effective upon my h might be transferred or distributed to me from any other person, estate, trust, or other entity, as may be appropriate. However, Agent may not disclaim assets, to -3- which I would be entitled, ify of my assets to the trustee of any revocable trust created by me, if such trust exists at the time of such transfer. 17. To disclaim any interest (subject to other provisions of this document), whicsets to discharge any of my Agent's legal obligations, including any obligations of support which my Agent may owe to others, excluding those whom I am legally obligated to support. 16. To transfer anrs of my Agent's estate, (b) exercise any powers of appointment I may hold in favor of my Agent, my Agent's estate, my Agent's creditors, or the creditors of my Agent's estate, or (c) use any of my as authorized by this document, (a) gift, appoint, assign or designate any of my assets, interests or rights, directly or indirectly, to my Agent, my Agent's estate, my Agent's creditors, or the creditoift tax annual exclusion amount in any one calendar year, and this annual right shall be non-cumulative and shall lapse at the end of each calendar year. However, my Agent may not, unless specificallyorm Gifts to Minors Act or the Uniform Transfers To Minors Act. Any gifts made shall be limited to gifts that qualify for the federal gift tax annual exclusion, shall not exceed in value the federal gd if necessary, to file any state and federal gift tax returns and documents. Gifts to minors may be made to the minor directly or parent, guardian or close friend of the minor or pursuant to the Unif charitable contributions of my real, personal, tangible or intangible property, to such persons or organizations without regard to whether such gifts are a part of my estate planning or otherwise, anobtain or provide information to and from any agency, including governmental agencies, relating to tax matters and to negotiate, compromise or settle any matter with such agency. 15. To make gifts andny documents with any federal, state, local or other governmental body, including, but not limited to, federal, state, local or other income and tax returns and necessary and/or related documents; to ance as may be appropriate, including but not limited to, attorneys, accountants, investment professionals, brokers and real estate agents. 14. To prepare, or cause to be prepared, sign, and/or file astments. 12. To maintain and/or operate any business that I currently own or have an interest in or may own or have an interest in, in the future. 13. To employ any professional and/or business assistxamine, remove, keep or otherwise dispose of the contents. 11. To exercise any and all rights, including proxy rights, with respect to stocks, bonds, debentures, commodities, options or any other inveurities. -2- 10. To have access to any safe deposit box, vault or other storage area owned or leased by me alone or in conjunction with any other person, including access to their contents, and to en, firm, corporation or political entity; to perform any act necessary to deposit, negotiate, sell or transfer any note, security, or draft of the United States of America, including U.S. Treasury Secegotiating or endorsing any checks or other instruments, obtaining bank statements, passbooks, drafts, warrants, money orders, certificates, cashier checks, cash or vouchers payable to me by any personts with financial institutions; to conduct any business with any banking or financial institution with respect to any of my accounts, including, but not limited to, making deposits and withdrawals, ne bank accounts, including, but not limited to, checking accounts, savings accounts, certificates of deposit, investment accounts, brokerage accounts, retirement plan accounts, and other similar accoury and social security benefits), and to appoint anyone, including my Agent, to act as my "Representative Payee" for the purpose of receiving Social Security benefits. 9. To open, maintain and/or closre applications, provide information, and perform any other reasonable request by any government or its agencies in connection with governmental benefits (including but not limited to, medical, militaall payments I receive from any annuity, pension, retirement benefits, retirement plans, insurance benefits and government program including, but not limited to, Social Security and Medicare; to prepainsurance upon my life or the life of any other appropriate person and to make any elections and disclaimers under such policies. 8. To receive, deposit, hold, demand, deal with and/or sue to recover all monies which may become due and owing to me by reason of such transaction. 7. To apply for, purchase, maintain and/or deal with insurance and annuity contracts, insurance policies, including life sell or encumber any homestead that I now own or may own in the future; the right to remove tenants and to recover possession; and the right to ask for, demand, sue for, collect, recover and receive erty or asset whatsoever, tangible or intangible (now owned or acquired in the future by me) and to execute any necessary document, instrument or deed for such transactions. This includes the right toortgage, improve, repair, exchange, invest, reinvest and in any other manner (on such terms and at prices my Agent may deem proper) deal with all, any part or any interest in any real or personal prop or due in the future, owned by, due, owing payable, or belonging to, me or in which I have or may hereafter acquire any interest, to have, or use. 6. To maintain, manage, insure, lease, rent, sell, mhecks, drafts, causes of action, bequests, deposits, notes, interests, dividends, certificates of deposit, any and all documents of title and demands whatsoever, whether agreed to or disputed, now due claim, against me or asserted on my behalf against any other person or entity. -1- 5. To receive, hold, possess and/or invest any and all sums of money, accounts, debts, bonds, commercial papers, cever kind and nature as may be. 3. To request, ask, demand, sue and take any and all legal steps necessary to recover and collect any amount or debt owed to me. 4. To adjust, compromise and settle anytutions, proofs of loss, evidences of debts, releases, and satisfaction of mortgages, lien, judgments, security agreements and other debts and obligations and such other instruments in writing of whats, proxies, warrants, commercial papers, withdrawal and deposit slips, certificates of deposit of, or investments with or through banks, savings and loan, brokers, mutual fund companies or other insti covenants, conveyances, deeds, options, trust deeds, security agreements, leases, mortgages, notes, insurance policies, receipts, title documents, checks, drafts, letters of credit, stock certificatexecute any written agreement and document necessary to enter into any such contract and/or agreement, including but not limited to applications, assignments, bills of sale or lading, bonds, contracts,: 1. To conduct, engage in, and transact any and all lawful business of whatever kind or nature, on my behalf and in my name. 2. To enter into binding contracts on my behalf and to sign, endorse and esubstitute or substitutes, shall lawfully do or cause to be done by virtue of this power of attorney and the rights hereby granted. My Agent's powers and authority shall include, but not be limited toction, thing, business, property, real or personal, tangible or intangible, or matter whatsoever as I could do if personally present. I hereby ratify and confirm all acts that my Agent, or my Agent's hall have full power and authority to perform any act, power, duty, legal right or obligation whatsoever that I now have or may later acquire in connection with or relating to any person, item, transa___ maintaining an address at: _____________________________________________________ as my alternate or successor Agent, as necessary, to serve with the same powers, rights and discretions. My Agent s__________________ my true and lawful attorney-in-fact for me and in my name, and in my behalf. If the above named Agent is unable to serve for any reason, I appoint __________________________________ address at _______________________________________________ do hereby make and appoint ________________________________________ ("Agent") maintaining an address at: ___________________________________r legal responsibilities of an agent. -3- DURABLE POWER OF ATTORNEY Effective upon Disability KNOW ALL PERSONS BY THESE PRESENTS: I, ____________________________________ ("Principal") maintaining anand other health-care decisions for you. You may revoke this power of attorney if you later wish to do so. AGENT: By accepting or acting under the appointment, the agent assumes the fiduciary and othee of this power of attorney document, is legally binding upon you. If you have any questions about these powers, obtain competent legal advice. This document does not authorize anyone to make medical agent") with the power to handle business and legal matters on your behalf, including the power to sell, mortgage or dispose of your property. Any such action undertaken by your agent, within the scopION! PRINCIPAL: The Powers granted by this power of attorney document are broad and sweeping. Before signing this document, consider its consequences. You ("principal") are providing another person ("n is general information that is not state specific. Whenever appropriate, the instructions included with the forms packages offered for sale, generally include state specific instructions. -2- CAUTesses are necessary, if the Agent will deal with any real estate in Florida. Please note that this information is not intended as and is not a substitute for legal advice. Furthermore, this informatioe Power of Attorney to be recorded as a public record, if necessary. Although, some states don't require that a Durable Power of Attorney be witnessed, it is always a very good idea to do so. Two witnspecially if the Agent will be dealing with any real property. Notarization will make it more difficult for any third party to challenge the validity of the Power of Attorney and will allow the Durablorney is signed, in the event the original Agent is unable to serve or continue to serve as the Agent. A Durable Power of Attorney should always be notarized, even if your state does not require it, eof Attorney at any time. Since this Durable Power of Attorney takes effect only after the Principal becomes disabled or incompetent, an alternate Agent can be designated, at the time this Power of Attn the Principal. This is especially important if the Principal is incapacitated when the Power of Attorney goes into effect, or the Agent undertakes the acts. The Principal can revoke a Durable Power ney. A Power of Attorney is a "powerful" instrument and should be granted with care. Any action undertaken by the Agent, within the scope of the Power of Attorney document, will be legally binding uponey" is not used here to mean "lawyer". The person acting as the attorney-in-fact for the Principal does not need to be a lawyer. Almost anyone can be appointed an attorney-in-fact by a power of attort") to act on his or her behalf, even if the Principal later becomes incapacitated. This particular Form becomes effective upon the disability or incapacity of the Principal. Note that the word "attorctive upon Disability A Durable Power of Attorney allows a natural "mentally competent " person (called the "Principal" or "Principal") to authorize someone else (called the "Agent" or "AttorneyIn-Facting a document with another party. [_] The purchase and use of these forms, is subject to the Disclaimers and Terms of Use found at findlegalforms.com -1- Information Durable Power of Attorney Effe not a substitute for legal advice. These forms should only be a starting point for you and should not be used without consulting with an attorney first. An Attorney should be consulted before negotiahoice as Agent is unable to serve or continue to serve 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 sweeping, as the Agent has the power to handle business and legal matters on the Principal's behalf. [_] This document offers the option of nominating an alternate Agent in the event that the first cthe Agent (or attorney-in-fact) as to the tasks the Agent should complete. The Grantor should also be very careful in the selection of the Agent. The powers granted by this document are very broad and a witness. [_] The Principal should keep the original document, as well as a copy. The Agent should have access to the original document as needed. [_] The Principal should be careful in instructing ecord, if necessary. [_] Two witnesses need to sign the Power of Attorney. The witnesses should be competent adults. Anyone related by blood or marriage to the Principal, Agent or Notary should not beincipal. [_] 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 OhioOhio ______ Signature of person taking acknowledgment (Notary Public) _________________________________ Name typed, printed, or stamped -5- __________, ______ by __________________________ (name of Principal), who is personally known to me or who has produced ________________________________ as identification. ___________________________: ___________________________________ State of __________________________ ) ) ss County of ________________________ ) The foregoing instrument was acknowledged before me this _____ day of ______________________ State: ___________________________________ Witness Signature: ___________________________________ Name: ___________________________________ City: __________________________________ State_______ (state). ________________________________ Signature of Principal Witness Signature: ___________________________________ Name: ___________________________________ City: ______________________is Power of Attorney. I may revoke this Power of Attorney at any time by providing written notice to my Agent. Signed on ________________ (date), at _______________________ (city), ___________________ting 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 acting under the authority of thed 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 shall not be liable for losses resule 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 General Power of Attorney is terminatt 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 third party has actual knowledgy 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 to a general power of appointmensition 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 (a) my income to be taxable to mll 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 power-ofattorney or as to the disposcope 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 unaffected parts of the document sha Agent. This Power of Attorney shall be construed broadly as a General Power of Attorney. The listing of specific terms, rights, acts or powers are not intended to restrict or limit the definition or s 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 handled and all acts performed as myall 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 compensation for any services provided aack of capacity to receive and evaluate information effectively, to communicate decisions, and/or to manage my financial resources and affairs properly. My Agent shall be entitled to reimbursement of , and -3- authority of this document shall remain in full force and effect thereafter until my death or until my disability or incapacity. As used herein, "disability" or "incapacity" shall mean a ly Agent or my Agent's estate. This General Power of Attorney and the rights, powers, and authority of my Agent shall become effective immediately upon execution of this instrument. The rights, powersstate, trust, or other entity, as may be appropriate. However, Agent may not disclaim assets, to which I would be entitled, if the result is that the disclaimed assets pass directly or indirectly to mif 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 any other person, e 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 trust created by me, y 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 obligations, including any 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 of appointment I mannual 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, assign or designategifts 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 calendar year, and this aocuments. 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 To Minors Act. Any le 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 gift tax returns and drnmental 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, tangible or intangibdy, 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 agency, including gove 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 other governmental boy 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 limited to, attorneys, any and all rights, including proxy rights, with respect to stocks, bonds, debentures, commodities, options or any other investments. -2- 12. To maintain and/or operate any business that I currentlstorage 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 contents. 11. To exercisery to deposit, negotiate, sell or transfer any note, security, or draft of the United States of America, including U.S. Treasury Securities. 10. To have access to any safe deposit box, vault or other ank statements, passbooks, drafts, warrants, money orders, certificates, cashier checks, cash or vouchers payable to me by any person, firm, corporation or political entity; to perform any act necessanking 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 instruments, obtaining bavings accounts, certificates of deposit, investment accounts, brokerage accounts, retirement plan accounts, and other similar accounts with financial institutions; to conduct any business with any bay 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, checking accounts, sle 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 anyone, including ms, retirement plans, insurance benefits and government program including, but not limited to, Social Security and Medicare; to prepare applications, provide information, and perform any other reasonabnd 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, retirement benefitansaction. 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 appropriate person aure; 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 by reason of such trred 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 or may own in the futr 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 (now owned or acqui, 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, reinvest and in any otheidends, certificates of deposit, any and all documents of title and demands whatsoever, whether agreed to or disputed, now due or due -1- in the future, owned by, due, owing payable, or belonging to or entity. 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, deposits, notes, interests, divtake 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 against any other personion 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, ask, demand, sue and s, 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, releases, and satisfactments, leases, mortgages, notes, insurance policies, receipts, title documents, checks, drafts, letters of credit, stock certificates, proxies, warrants, commercial papers, withdrawal and deposit slipy such contract and/or agreement, including but not limited to applications, assignments, bills of sale or lading, bonds, contracts, covenants, conveyances, deeds, options, trust deeds, security agree 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 necessary to enter into anvirtue 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 all lawful businessngible, 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 cause to be done by 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 personal, tangible or inta____________________________________________ my true and lawful attorney-in-fact for me and in my name, and in my behalf. My Agent shall have full power and authority to perform any act, power, duty, Principal") maintaining an address at _______________________________________________ do hereby make and appoint ________________________________________ ("Agent") maintaining an address at: _________ppointment, the agent assumes the fiduciary and other legal responsibilities of an agent. -3- GENERAL POWER OF ATTORNEY KNOW ALL PERSONS BY THESE PRESENTS: I, ____________________________________ ("document does not authorize anyone to make medical and other health-care decisions for you. You may revoke this power of attorney if you later wish to do so. AGENT: By accepting or acting under the ach action undertaken by your agent, within the scope of this power of attorney document, is legally binding upon you. If you have any questions about these powers, obtain competent legal advice. This . You ("principal") are providing another person ("agent") with the power to handle business and legal matters on your behalf, including the power to sell, mortgage or dispose of your property. Any sully include state specific instructions. -2- CAUTION! PRINCIPAL: The Powers granted by this power of attorney document are broad and sweeping. Before signing this document, consider its consequencestute for legal advice. Furthermore, this information is general information that is not state specific. Whenever appropriate, the instructions included with the forms packages offered for sale, generatorneys (available at findlegalforms.com as well), stays in effect even if the Grantor later becomes disabled or incapacitated. Please note that this information is not intended as and is not a substiif necessary. Although, some states don't require that a General Power of Attorney be witnessed, it is always a very good idea to do so. Another type of Power of Attorney, called a Durable Power of Atoperty. Notarization will make it more difficult for any third party to challenge the validity of the Power of Attorney and will allow the General Power of Attorney to be recorded as a public record, revoke a General Power of Attorney at any time. A General Power of Attorney should always be notarized, even if your state does not require it, especially if the Agent will be dealing with any real prpowerful" instrument and should be granted with care. Any action undertaken by the Agent, within the scope of the Power of Attorney document, will be legally binding upon the Grantor. The Grantor can ney-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. The Agent should be a competent adult. A Power of Attorney is a "remains effective until the death of the Grantor or until the Grantor becomes disabled or incapacitated. Note that the word "attorney" is not used here to mean "lawyer". The person acting as the Attornt person (called the "Principal" or "Grantor") to authorize someone else (called the "Agent" or "Attorney-InFact") to act on his or her behalf. This particular Form becomes effective immediately and se of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com -1- Information General Power of Attorney A General Power of Attorney allows a natural "mentally" competebe a starting point for you and should not be used without consulting with an attorney first. An Attorney should be consulted before negotiating any document with another party. [_] The purchase and uweeping, as the Agent has the power to handle business and legal matters on the Principal's behalf. [_] These forms are not intended and are not a substitute for legal advice. These forms should only e Agent (or attorney-in-fact) as to the tasks the Agent should complete. The Grantor should also be very careful in the selection of the Agent. The powers granted by this document are very broad and sitnesses. [_] The Principal should keep the original document, as well as a copy. The Agent should have access to the original document as needed. [_] The Principal should be careful in instructing tha public record, if necessary. [_] Two witnesses need to sign the Power of Attorney. The witnesses should be competent adults. The Agent, the Agent's spouse or children, and the Notary should not be wncipal (i.e. the person granting the Power of Attorney; sometimes called the Grantor) should sign the document before a Notary. Notarization will allow the General Power of Attorney to be recorded as er of Attorney [_] This General Power of Attorney becomes effective immediately and remains effective until the death of the Grantor or until the Grantor becomes disabled or incapacitated. [_] The PriInstructions & Checklist General Power of Attorney [_] This package contains (1) Instructions & Checklist for General Power of Attorney; (2) Information for General Power of Attorney; (3) General Pow OhioOhio L] ________ , and ___________________________________ witnesses, this _______ day of __________________, 20____. __________________________________________ Notary public Self-proved Will Affidavit [SEAcknowledged before me ________________________________ a notary public, and by _________________________________________, the testatrix, and by ___________________________________ , _________________________________________ _____________________________________________ (Witness) Print Name: ___________________________________ Address: ______________________________________ Subscribed, sworn, and a_______________________ Address: ______________________________________ _____________________________________________ (Witness) Print Name: ___________________________________ Address: _______________over 18 years of age and otherwise competent to be a witness. _____________________________________________ (Testatrix) _____________________________________________ (Witness) Print Name: ____________as witness, and that to the best of the witness's knowledge the testatrix was at that time 18 years of age or older, of sound mind, and under no constraint or undue influence and that each witness is ), that the testatrix executed it as the testatrix's free and voluntary act for the purposes expressed in it, that each of the witnesses, in the presence and hearing of the testatrix, signed the will ity under penalty of perjury that the testatrix signed and executed the instrument as the testatrix's will, that the testatrix signed willingly (or willingly directed another to sign for the testatrix whose names are signed to the attached or foregoing instrument in those capacities, personally appearing before the undersigned authority and being first duly sworn, declare to the undersigned author___ We, ________________________________, and _______________________________, and ________________________________ and ________________________________, the testatrix and the witnesses, respectively,: __________ Testatrix/Wife __________ Witness __________ __________ Witness Witness Page 7 of ______ Self-Proved Will Affidavit STATE OF __________________________ COUNTY OF _______________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Initials______________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ _________________________te: Witness Signature: Name: Address: City: State: ___________________________________ ___________________________________ ___________________________________ ___________________________________ _____tent witness, and resides at the address set forth after his or her name. Dated: ____________________, ______ Witness Signature: Name: Address: City: State: Witness Signature: Name: Address: City: Stastatrix is of sound mind and memory; We believe that this Will was not procured by duress, menace, fraud or undue influence; The maker is age 18 or older. Each of us is now age 18 or older, is a comped at Testatrix's request, and in the sight and presence of each other, do hereby subscribe our names as witnesses on the date shown above. We understand this is the Testatrix's Will; We believe the Tesence by _____________________________ (the "Testatrix"), who declared this instrument to be her Last Will and Testament and we, at the Testatrix's request and in the Testatrix's sight and presence aning the page(s) which contain the witness signatures, was signed in our sight and Initials: __________ Testatrix/Wife __________ Witness __________ __________ Witness Witness Page 6 of ______ prehis Will.) We, the undersigned, hereby certify and declare under penalty of perjury under the laws of the State of ____________________ that the above instrument, which consists of _____ pages, includ____________________________ (Notice to Witnesses: Three (3) adults must sign as witnesses. Each witness must read the following clause before signing. The witnesses should not receive assets under tI make this under no constraint or undue influence and ask the Witnesses named below to witness my signature. Testatrix's Signature: _______________________________________________ Name: _____________e below to this Will, this _____ day of ____________________, ______. at ____________________ (city), that I declare this to be my Last Will and Testament, that I am of legal age and sound mind, that rvived me. In that case, the terms of his Will shall then take precedence over the terms of this Will or it's Codicils, except where otherwise directed by law. IN WITNESS WHEREOF, I have signed my nam whereby it is difficult or impractical to determine the order of deaths or to determine who survived the death of the other Spouse or who died first, I direct that it be determined that my Husband suunenforceable, any invalidity, illegality or unenforceability should affect only that provision and all other provision should remain effective. 7. Survival If my Husband and I die under circumstancesain the separate property of a beneficiary hereunder, free from all matrimonial rights or controls by his or her spouse. 6. Severability. If any provision of this Will is declared invalid, illegal or ity of property, partnership or other form of sharing or division of property which may exist between any beneficiary and his or her spouse, and every gift together with the income therefrom shall rem by such beneficiaries if they can agree, and if not, by my Executor. 5. Matrimonial Rights. No gift, or the income therefrom, under this Will shall be assigned or anticipated, or fall into any communiciary Disputes. If any bequest requires that the bequest be distributed between or among two or more beneficiaries, the specific items of property comprising the respective shares shall be determinedconnection with or arising out of that fiduciary's good faith actions or non-actions as the fiduciary, except for such actions or non-actions which constitute fraudulent conduct or bad faith. 4. Benefll, in the absence of fraudulent conduct or bad faith, be liable individually to any beneficiary of my estate, and my estate shall indemnify such natural person from any and all claims or expenses in date of my death. Initials: __________ Testatrix/Wife __________ Witness __________ __________ Witness Witness Page 5 of ______ 3. Liability of Fiduciary. No fiduciary who is a natural person shaFor the purposes of determining the appropriate distributions under this Will, Each beneficiary shall be deemed not to have survived me unless the beneficiary is living on the thirtieth day after the such adopted person's descendants, if, but only if, the adopted person is not more than twelve years of age on the date of the court order granting such adoption. 2. Thirty Day Survival Requirement. plural, and vice versa. and any pronouns shall be taken to refer to the person or persons intended regardless of gender or number The terms "child" and "descendant" shall include an adopted person and not to be considered as forming a part of this Will in interpreting its provisions. Throughout this Will the use of any gender shall be deemed to include all genders, and the use of the singular the r the distribution of my estate shall be supplemented by the following: 1. Paragraph Titles and Gender. The titles given to the paragraphs of this Will are inserted for reference purposes only and are and shall not be subject to any question or review, by any person, official, authority, court or tribunal whatsoever or whomsoever. ARTICLE VII MISCELLANEOUS PROVISIONS The provisions in this Will foheir duties hereunder or as not being maintenance of an even-hand among the beneficiaries and all such exercise of their powers, authority and discretion shall be binding upon all of the beneficiaries exercise may have the effect of conferring an advantage on any one or more of the beneficiaries or would otherwise, but for the foregoing, be considered as being other than an impartial exercise of tThe Executor shall exercise the powers, authority and discretion granted herein in what Executor deems to be the best interest, whether monetary or otherwise, of the beneficiaries, whether or not suchprotected in exercising any discretion granted to them in my Will and shall not be liable to the beneficiaries or their heirs or personal representatives by reason of the exercise of such discretion. nable expenses and costs incurred in connection with administering my estate, including but not limited to attorney, accountant, agent, broker and other professional fees. The Executor shall be fully no consideration and upon such terms and conditions as the Executor may deem advisable and to refer to arbitration all such claims if the Executor deem same advisable. 11. Pay all necessary and reasoy have an interest at the time of my death. 10. Compromise, settle, waive or pay any claim or claims at any time owing by my estate or which my estate may have against others for such consideration orth. Initials: __________ Testatrix/Wife __________ Witness __________ __________ Witness Witness Page 4 of ______ 9. Windup, dissolve, settle or continue any partnership or business in which I maoss, claim, tax or other cost experienced by any such person or by my estate resulting from any election, determination, designation or exercise of discretion, entered into by the Executor in good faise of discretion by the Executor shall be conclusive and binding upon all the beneficiaries hereof. The Executor shall not be liable to any person, whether beneficiary or otherwise, by reason of any lal government of the United States of America, by the legislature or government of any state, or by any other legislative or governmental body of any other country, state or territory, and such exerciny such property so used. 8. Make or refrain from making, in Executor's absolute discretion, any elections, determinations, and designations permitted by any statute or regulation enacted by the federithout paying any rent, without giving any bond or security and without liability for any loss or damage. The Executor shall not be liable or responsible for any injury to, consumption of or loss of ao possession and no such interest not actually producing income shall be treated as producing income. 7. Permit any beneficiaries of my estate to use any tangible personal property or real property, woss to the intent that investments or assets so retained shall be deemed to be authorized investments for all purposes of my Will. No reversionary or future interest shall be sold prior to falling introperty or undivided fractional share in property. 6. Retain any of my investments or assets in the form existing at the date of my death at Executor's absolute discretion without responsibility for l think best. Make any division or distribution of my residuary estate in money or in other property or partly in both upon the basis of fair market value and cause any share to be composed of money, pedit or for part cash and part credit as they may in their absolute discretion decide upon, or to postpone such conversion of my estate or any part or parts thereof for such length of time as they mayr any part thereof so valued. 5. Sell, call in and convert into money any part of my estate not consisting of money at such time or times, in such manner and upon such terms, and either for cash or crl be final and binding upon all persons concerned, notwithstanding any fluctuation in market value and notwithstanding that one or more of the Executor may be beneficially interested in the property oe Executor shall in their absolute discretion fix the value of my estate or any part thereof for the purpose of making any such division, setting aside or payment and the decision of the Executor shalor interest therein either wholly or in part in the assets forming my estate at the time of my death or at the time of such division, setting aside or payment, and I expressly will and declare that thor mortgages and to pay off any mortgage or mortgages which may be in existence at any time forming part of my estate. 4. Make any division of my real or personal estate or set aside or pay any share right to renew and keep renewed any mortgage or mortgages upon any real estate forming part of my estate or any part thereof, to borrow money on any such real estate upon the security of any mortgage ____ 3. To accept surrenders of leases and tenancies, to expend money in repairs, alterations, rebuilding and improvements and generally to manage any such property. The Executor shall also have the dition and repair, in the manner and to the extent that the Executor shall deem advisable. Initials: __________ Testatrix/Wife __________ Witness __________ __________ Witness Witness Page 3 of __stration of my estate for such period as the Executor shall determine; collect any income therefrom; and pay the taxes and expenses thereof, including the cost of keeping such property in adequate conbe necessary to effect such a sale, mortgage, lease or other disposition. The power of sale herein is discretionary and not mandatory. 2. Take charge of any real property as part of the probate adminideemed advisable, without order of court and without notice to anyone. I also give to the Executor power to execute and deliver such deeds, mortgages, leases or other instruments and documents as may dispose of all or part of any real or personal property that may be included in my estate in such manner and for such purposes, for such prices, and upon such terms, credits and conditions as may be necessary or appropriate for proper administration of my estate, the Executor shall have the right and power to: 1. Lease, sell, grant options, partition, exchange, mortgage, or otherwise encumber orshall be required of any Executor serving hereunder. ARTICLE VI POWERS OF EXECUTOR In addition to the existing authority of the Executor and in addition to other powers and authority granted by law or my estate, using "informal", "unsupervised", or "independent" probate or equivalent legislation designed to operate without unnecessary intervention by the probate court. No bond, security or surety ituted and whether one or more. To the extent permitted by law, the Executor shall have the right to administer my estate without adjudication, order or direction of the court having jurisdiction over in this my Will shall include each Executor, Executrix, and Personal Representatives of my Will, my estate or any portion thereof who may be acting as such from time to time whether original or substerve or continue to serve as Executor for any reason, I appoint ___________________________________, , to be the Executor of this my Will in the place and stead of my Husband. References to "Executor"t discharge to the Executor. ARTICLE V NOMINATION OF EXECUTOR I appoint my Husband ___________________________________, as the Executor of this my Will. If my Spouse cannot, does not or is unable to sWitness Witness Page 2 of ______ the time of the distribution or to any other person the Executor may consider to be a proper recipient thereof. Receipt of any such distribution shall be a sufficient, guardian, conservator, committee of such person, trustee of such person, person with whom the beneficiary resides at Initials: __________ Testatrix/Wife __________ Witness __________ __________ e before attaining the age of majority or while under any other disability, I authorize the Executor to nevertheless make any distribution for any such person directly to the beneficiary or to a parenhe time fixed for distribution under this provision. Except as may be specifically otherwise provided herein or directed otherwise by law, if any person should become entitled to any share in my estathall be distributed to my heirs-at-law, their identities and respective shares to be determined under the laws of the State of ________________________, then in effect, as if I had died intestate at t_______(name(s) beneficiary(ies)). If more than one beneficiary is named, then the distribution shall be in equal shares per stirpes. If any such beneficiary does not survive me, my residuary estate sroperty not otherwise disposed of by this Will, shall be distributed to: ________________________________________________________________ ______________________________________________________________al property and personal property, be distributed, bequeathed and given to my Spouse. ______________________________________. If my Spouse does not survive me, then my residuary estate and any other p___________________________________. If my Husband does not survive me, this bequest shall be distributed with my residuary estate. Residuary Estate I direct that my residuary estate, including any reficiary does not survive me, this bequest shall be distributed with my residuary estate. Primary Residence My interest in my primary residence or homestead, if any, shall be distributed to my Husband does not survive me, this bequest shall be distributed with my residuary estate. _____________________________________________ shall be distributed to ___________________________________. If this bene survive me, this bequest shall be distributed with my residuary estate. _____________________________________________ shall be distributed to ___________________________________. If this beneficiary ect that the following specific bequests be made from my estate. _____________________________________________ shall be distributed to ___________________________________. If this beneficiary does not__ Witness Witness Page 1 of ______ purchaser or transferee upon or after my death pursuant to any agreement with respect to such property. ARTICLE IV DISPOSITION OF PROPERTY Specific Bequests I dirh taxes that may be payable by a purchaser or transferee in connection with any property transferred to or acquired by such Initials: __________ Testatrix/Wife __________ Witness __________ ________taxes are owed by my estate or by any beneficiary. The Executor shall not be seek reimbursement from any beneficiary for the payment of the taxes. This direction shall not extend to or include any succonnection with any insurance on my life or any gift or benefit given or conferred by me either during my lifetime or by survivorship. The payment of the taxes shall be made regardless of whether the sary to pay said inheritance taxes. The payment of the taxes shall be made regardless of whether the taxes are owed on property passing under this Will or any codicil hereto, outside of this Will, in ed because of my death shall be paid out of the residue of my estate. The Executor shall create, out of the residue, a separate fund for the purpose of paying any inheritance taxes in the amount neceses and expenses of last illness be first paid out of and charged to the capital of my general estate. All taxes (including income taxes and inheritance taxes) and any interest and penalties thereon ows and markers, regardless of any limitation fixed by statute or rule of court and without order of any court. ARTICLE III PAYMENT OF DEBTS AND EXPENSES I direct that my just debts, testamentary expens as the Executor deems proper for my funeral, cremation or burial and interment, including the disposition of the ashes or the acquisition of any burial site and the erection and engraving of monuments to "my Husband" refer to _____________________________________ (name of husband). I don't have any children. ARTICLE II FUNERAL & BURIAL EXPENSES I authorize the Executor of my Will to pay such sumsy former Wills and Codicils and publish and declare this to be my Last Will and Testament. ARTICLE I SPOUSE I am married to ___________________________________________ (name of husband). All referenceill Affidavit [SEAL] Last Will And Testament Of ______________________ I, _____________________________________ (name), of _______________________ (county), _______________________ (state), revoke m __________________________ , and ___________________________________ witnesses, this _______ day of __________________, 20____. __________________________________________ Notary public Self-proved Wcribed, sworn, and acknowledged before me ________________________________ a notary public, and by _________________________________________, the testator, and by ___________________________________ ,ess: ______________________________________ _____________________________________________ (Witness) Print Name: ___________________________________ Address: ______________________________________ Subst Name: ___________________________________ Address: ______________________________________ _____________________________________________ (Witness) Print Name: ___________________________________ Addrthat each witness is over 18 years of age and otherwise competent to be a witness. _____________________________________________ (Testator) _____________________________________________ (Witness) Prinator, signed the will as witness, and that to the best of the witness's knowledge the testator was at that time 18 years of age or older, of sound mind, and under no constraint or undue influence and to sign for the testator), that the testator executed it as the testator's free and voluntary act for the purposes expressed in it, that each of the witnesses, in the presence and hearing of the testare to the undersigned authority under penalty of perjury that the testator signed and executed the instrument as the testator's will, that the testator signed willingly (or willingly directed another the witnesses, respectively, whose names are signed to the attached or foregoing instrument in those capacities, personally appearing before the undersigned authority and being first duly sworn, declOUNTY OF ________________________ We, ________________________________, and _______________________________, and ________________________________ and ________________________________, the testator and__________________________ Initials: __________ Testator __________ Witness __________ __________ Witness Witness Page 7 of ______ Self-Proved Will Affidavit STATE OF __________________________ C__________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ _______________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ _________________________ Signature: Name: Address: City: State: Witness Signature: Name: Address: City: State: ___________________________________ ___________________________________ ___________________________________ _____s is now age 18 or older, is a competent witness, and resides at the address set forth after his or her name. Dated: ____________________, ______ Witness Signature: Name: Address: City: State: Witnesshe Testator's Will; We believe the Testator is of sound mind and memory; We believe that this Will was not procured by duress, menace, fraud or undue influence; The maker is age 18 or older. Each of udo hereby Initials: __________ Testator __________ Witness __________ __________ Witness Witness Page 6 of ______ subscribe our names as witnesses on the date shown above. We understand this is ted this instrument to be his Last Will and Testament and we, at the Testator's request and in the Testator's sight and presence and at Testator's request, and in the sight and presence of each other, nstrument, which consists of _____ pages, including the page(s) which contain the witness signatures, was signed in our sight and presence by _____________________________ (the "Testator"), who declar The witnesses should not receive assets under this Will.) We, the undersigned, hereby certify and declare under penalty of perjury under the laws of the State of ____________________ that the above i____________________________ Name: _________________________________________ (Notice to Witnesses: Three (3) adults must sign as witnesses. Each witness must read the following clause before signing.ent, that I am of legal age and sound mind, that I make this under no constraint or undue influence and ask the Witnesses named below to witness my signature. Testator's Signature: ___________________ by law. IN WITNESS WHEREOF, I have signed my name below to this Will, this _____ day of ____________________, ______. at ____________________ (city), that I declare this to be my Last Will and Testamied first, I direct that it be determined that I survived my Wife. In that case, the terms of this Will shall then take precedence over any Will or Codicils of my Wife, except where otherwise directedective. 7. Survival If my Wife and I die under circumstances whereby it is difficult or impractical to determine the order of deaths or to determine who survived the death of the other Spouse or who d If any provision of this Will is declared invalid, illegal or unenforceable, any invalidity, illegality or unenforceability should affect only that provision and all other provision should remain effse, and every gift together with the income therefrom shall remain the separate property of a beneficiary hereunder, free from all matrimonial rights or controls by his or her spouse. 6. Severability. Will shall be assigned or anticipated, or fall into any community of property, partnership or other form of sharing or division of property which may exist between any beneficiary and his or her spouf property comprising the respective shares shall be determined by such beneficiaries if they can agree, and if not, by my Executor. 5. Matrimonial Rights. No gift, or the income therefrom, under thisions which constitute fraudulent conduct or bad faith. 4. Beneficiary Disputes. If any bequest requires that the bequest be distributed between or among two or more beneficiaries, the specific items oness __________ __________ Witness Witness Page 5 of ______ connection with or arising out of that fiduciary's good faith actions or non-actions as the fiduciary, except for such actions or non-actd faith, be liable individually to any beneficiary of my estate, and my estate shall indemnify such natural person from any and all claims or expenses in Initials: __________ Testator __________ Witd me unless the beneficiary is living on the thirtieth day after the date of my death. 3. Liability of Fiduciary. No fiduciary who is a natural person shall, in the absence of fraudulent conduct or bart order granting such adoption. 2. Thirty Day Survival Requirement. For the purposes of determining the appropriate distributions under this Will, Each beneficiary shall be deemed not to have survivehe terms "child" and "descendant" shall include an adopted person and such adopted person's descendants, if, but only if, the adopted person is not more than twelve years of age on the date of the coull be deemed to include all genders, and the use of the singular the plural, and vice versa. and any pronouns shall be taken to refer to the person or persons intended regardless of gender or number Tagraphs of this Will are inserted for reference purposes only and are not to be considered as forming a part of this Will in interpreting its provisions. Throughout this Will the use of any gender sha. ARTICLE VII MISCELLANEOUS PROVISIONS The provisions in this Will for the distribution of my estate shall be supplemented by the following: 1. Paragraph Titles and Gender. The titles given to the parthority and discretion shall be binding upon all of the beneficiaries and shall not be subject to any question or review, by any person, official, authority, court or tribunal whatsoever or whomsoeverregoing, be considered as being other than an impartial exercise of their duties hereunder or as not being maintenance of an even-hand among the beneficiaries and all such exercise of their powers, auther monetary or otherwise, of the beneficiaries, whether or not such exercise may have the effect of conferring an advantage on any one or more of the beneficiaries or would otherwise, but for the forsonal representatives by reason of the exercise of such discretion. The Executor shall exercise the powers, authority and discretion granted herein in what Executor deems to be the best interest, wheent, broker and other professional fees. The Executor shall be fully protected in exercising any discretion granted to them in my Will and shall not be liable to the beneficiaries or their heirs or pe if the Executor deem same advisable. 11. Pay all necessary and reasonable expenses and costs incurred in connection with administering my estate, including but not limited to attorney, accountant, ag or which my estate may have against others for such consideration or no consideration and upon such terms and conditions as the Executor may deem advisable and to refer to arbitration all such claimsth. Initials: __________ Testator __________ Witness __________ __________ Witness Witness Page 4 of ______ 10. Compromise, settle, waive or pay any claim or claims at any time owing by my estategnation or exercise of discretion, entered into by the Executor in good faith. 9. Windup, dissolve, settle or continue any partnership or business in which I may have an interest at the time of my dea liable to any person, whether beneficiary or otherwise, by reason of any loss, claim, tax or other cost experienced by any such person or by my estate resulting from any election, determination, desigovernmental body of any other country, state or territory, and such exercise of discretion by the Executor shall be conclusive and binding upon all the beneficiaries hereof. The Executor shall not bend designations permitted by any statute or regulation enacted by the federal government of the United States of America, by the legislature or government of any state, or by any other legislative or not be liable or responsible for any injury to, consumption of or loss of any such property so used. 8. Make or refrain from making, in Executor's absolute discretion, any elections, determinations, aries of my estate to use any tangible personal property or real property, without paying any rent, without giving any bond or security and without liability for any loss or damage. The Executor shall Will. No reversionary or future interest shall be sold prior to falling into possession and no such interest not actually producing income shall be treated as producing income. 7. Permit any beneficia of my death at Executor's absolute discretion without responsibility for loss to the intent that investments or assets so retained shall be deemed to be authorized investments for all purposes of my e basis of fair market value and cause any share to be composed of money, property or undivided fractional share in property. 6. Retain any of my investments or assets in the form existing at the date my estate or any part or parts thereof for such length of time as they may think best. Make any division or distribution of my residuary estate in money or in other property or partly in both upon thime or times, in such manner and upon such terms, and either for cash or credit or for part cash and part credit as they may in their absolute discretion decide upon, or to postpone such conversion ofne or more of the Executor may be beneficially interested in the property or any part thereof so valued. 5. Sell, call in and convert into money any part of my estate not consisting of money at such tch division, setting aside or payment and the decision of the Executor shall be final and binding upon all persons concerned, notwithstanding any fluctuation in market value and notwithstanding that oivision, setting aside or payment, and I expressly will and declare that the Executor shall in their absolute discretion fix the value of my estate or any part thereof for the purpose of making any sue any division of my real or personal estate or set aside or pay any share or interest therein either wholly or in part in the assets forming my estate at the time of my death or at the time of such d to borrow money on any such real estate upon the security of any mortgage or mortgages and to pay off any mortgage or mortgages which may be in existence at any time forming part of my estate. 4. Mak________ __________ Witness Witness Page 3 of ______ shall also have the right to renew and keep renewed any mortgage or mortgages upon any real estate forming part of my estate or any part thereof,eases and tenancies, to expend money in repairs, alterations, rebuilding and improvements and generally to manage any such property. The Executor Initials: __________ Testator __________ Witness __and expenses thereof, including the cost of keeping such property in adequate condition and repair, in the manner and to the extent that the Executor shall deem advisable. 3. To accept surrenders of l not mandatory. 2. Take charge of any real property as part of the probate administration of my estate for such period as the Executor shall determine; collect any income therefrom; and pay the taxes deliver such deeds, mortgages, leases or other instruments and documents as may be necessary to effect such a sale, mortgage, lease or other disposition. The power of sale herein is discretionary andpurposes, for such prices, and upon such terms, credits and conditions as may be deemed advisable, without order of court and without notice to anyone. I also give to the Executor power to execute andase, sell, grant options, partition, exchange, mortgage, or otherwise encumber or dispose of all or part of any real or personal property that may be included in my estate in such manner and for such y of the Executor and in addition to other powers and authority granted by law or necessary or appropriate for proper administration of my estate, the Executor shall have the right and power to: 1. Lethout unnecessary intervention by the probate court. No bond, security or surety shall be required of any Executor serving hereunder. ARTICLE VI POWERS OF EXECUTOR In addition to the existing authoritte without adjudication, order or direction of the court having jurisdiction over my estate, using "informal", "unsupervised", or "independent" probate or equivalent legislation designed to operate wiion thereof who may be acting as such from time to time whether original or substituted and whether one or more. To the extent permitted by law, the Executor shall have the right to administer my estacutor of this my Will in the place and stead of my Wife. References to "Executor" in this my Will shall include each Executor, Executrix, and Personal Representatives of my Will, my estate or any portecutor of this my Will. If my Wife cannot, does not or is unable to serve or continue to serve as Executor for any reason, I appoint __________________________________________________, , to be the Exeals: __________ Testator __________ Witness __________ __________ Witness Witness Page 2 of ______ ARTICLE V NOMINATION OF EXECUTOR I appoint my Wife ___________________________________, as the Exthe time of the distribution or to any other person the Executor may consider to be a proper recipient thereof. Receipt of any such distribution shall be a sufficient discharge to the Executor. Initie any distribution for any such person directly to the beneficiary or to a parent, guardian, conservator, committee of such person, trustee of such person, person with whom the beneficiary resides at otherwise by law, if any person should become entitled to any share in my estate before attaining the age of majority or while under any other disability, I authorize the Executor to nevertheless makate of ________________________, then in effect, as if I had died intestate at the time fixed for distribution under this provision. Except as may be specifically otherwise provided herein or directed per stirpes. If any such beneficiary does not survive me, my residuary estate shall be distributed to my heirs-at-law, their identities and respective shares to be determined under the laws of the St_________________ _____________________________________________________________________(name(s) beneficiary(ies)). If more than one beneficiary is named, then the distribution shall be in equal shares____. If my Spouse does not survive me, then my residuary estate and any other property not otherwise disposed of by this Will, shall be distributed to: _______________________________________________ary estate. Residuary Estate I direct that my residuary estate, including any real property and personal property, be distributed, bequeathed and given to my Spouse. __________________________________rest in my primary residence or homestead, if any, shall be distributed to my Wife ___________________________________. If my Wife does not survive me, this bequest shall be distributed with my residu____________ shall be distributed to ___________________________________. If this beneficiary does not survive me, this bequest shall be distributed with my residuary estate. Primary Residence My inte____ shall be distributed to ___________________________________. If this beneficiary does not survive me, this bequest shall be distributed with my residuary estate. _________________________________ll be distributed to ___________________________________. If this beneficiary does not survive me, this bequest shall be distributed with my residuary estate. _________________________________________h respect to such property. ARTICLE IV DISPOSITION OF PROPERTY Specific Bequests I direct that the following specific bequests be made from my estate. _____________________________________________ shacquired by such Initials: __________ Testator __________ Witness __________ __________ Witness Witness Page 1 of ______ purchaser or transferee upon or after my death pursuant to any agreement witeficiary for the payment of the taxes. This direction shall not extend to or include any such taxes that may be payable by a purchaser or transferee in connection with any property transferred to or a lifetime or by survivorship. The payment of the taxes shall be made regardless of whether the taxes are owed by my estate or by any beneficiary. The Executor shall not seek reimbursement from any bens are owed on property passing under this Will or any codicil hereto, outside of this Will, in connection with any insurance on my life or any gift or benefit given or conferred by me either during myhe residue, a separate fund for the purpose of paying any inheritance taxes in the amount necessary to pay said inheritance taxes. The payment of the taxes shall be made regardless of whether the taxe taxes (including income taxes and inheritance taxes) and any interest and penalties thereon owed because of my death shall be paid out of the residue of my estate. The Executor shall create, out of turt. ARTICLE III PAYMENT OF DEBTS AND EXPENSES I direct that my just debts, testamentary expenses and expenses of last illness be first paid out of and charged to the capital of my general estate. Alln of the ashes or the acquisition of any burial site and the erection and engraving of monuments and markers, regardless of any limitation fixed by statute or rule of court and without order of any codren. ARTICLE II FUNERAL & BURIAL EXPENSES I authorize the Executor of my Will to pay such sums as the Executor deems proper for my funeral, cremation or burial and interment, including the dispositioment. ARTICLE I SPOUSE I am married to _____________________________________ (name of wife). All references to "my Wife" refer to ________________________________ (name of wife). I don't have any chil____________________________ (name), of _______________________ (county), _______________________ (state), revoke my former Wills and Codicils and publish and declare this to be my Last Will and Testang with estate planning matters. Any possible tax consequences arising out of this document should be discussed with a tax professional. Last Will And Testament Of ______________________ I, _________arting 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 when deali0 in 1999). This information and these forms are not intended and are not a substitute for legal and/or tax advice. Laws vary from time to time and from state to state. These forms should only be a st her spouse upon death without any federal estate tax liability. This is referred to as the "Marital Deduction". If the recipient spouse is not a U.S. citizen, the deduction is limited (it was $100,00yee benefit plans; [] the face value of any life insurance policy; [] property you are holding in trust; any joint property you own In addition, each individual may leave an unlimited amount to his or] tangible personal property (household furnishings and furniture, jewelry, art, and other personal effects); [] partnership (business) interests; [] individual retirement accounts and qualified emplotorney. Before using this Will, it may be helpful to determine the value of all of the assets in your estate. Assets may include the following: [] real estate; [] stocks and bonds; [] bank accounts; [onal estate tax planning advice If Information about Wills ­ Page 2 your assets come near the $1,000,000 level, you really shouldn't use this will and should consult with tax professionals and an athis or her spouse. Estates totaling $1,000,000 or more could be subject to federal estate tax. As your estate approaches $1,000,000 in value and exceeds that amount, the greater your need for professi the value of an individual's estate. For a person dying in 2003, that credit is $1,000,000. The amount of the credit increases over the next few years. The credit is available to each individual and t death taxes. Testators should have an understanding of tax laws. Federal tax law provides that upon the death of an individual, there is a credit against the estate tax otherwise due on a portion ofe Will is for anyone in any life situation where this Will is to be used as the principal estate planning document. If you have a large estate, you may need more complicated planning to reduce or limiffidavit of the witnesses or to require the witnesses to testify. New Hampshire permits self proving, but requires the affidavit to be in a specific format similar to the one included in our wills. Thes it will have to be "proven" in court, like any other will. In Ohio, Maryland, California and the District of Columbia, the courts have some latitude to accept a will as self proved, to require an aing wills. The affidavit will be of no use in those states. However, including the affidavit in those states will not invalidate the Will (since it is a separate document from the Will). In those statt on such grounds as undue influence, lack of testamentary capacity, or prior revocation. A few states like Louisiana, Maryland, Ohio and Vermont (as of 1999).do not have statutes permitting self provties in signing the Will were followed. The Affidavit can also be useful if witnesses are not available when they are needed.. However, even with the Affidavit, the Will may still be subject to contesh sworn affidavits, that each saw the Testator sign the will and that the formalities for signing a Will were followed. The Affidavit may eliminate the need to have witnesses testify, that the formaliWill to probate after the death of the Testator. Before the adoption of more modern laws, all wills were proved by having one or more of the witnesses come into court and testify under oath, or througefore a Notary, that all required formalities were observed when the Will was signed. The Affidavit does not affect the validity or legality of the Will. However, it can speed up the admission of the required to be probated and will not be governed by this Will. The Will has an enclosed self-proving affidavit, which contains the Testator's acknowledgment and the affidavit of the witnesses, made bbe distributed. Assets held jointly with rights of survivorship, assets with beneficiary designations (such as life insurance or employee benefit plans), and assets held in trust generally will not be the Will (the "Testator") as specified by the Testator. This Will does not avoid probate for the Testator's estate. It merely directs how the assets which are individually owned by the Testator will these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Checklist & Instructions ­ Page 5 Information about Wills This Will distributes the assets of the person makingey is always recommended when dealing with estate planning matters. Any possible tax consequences arising out of this document should be discussed with a tax professional. [_] The purchase and use of te. These forms should only be a starting point for you and should not be used or signed without consulting an attorney first to make sure it fits your particular situation. Advice from a local attornny 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 stawyer in their new state to make sure it meets local requirements. [_] These forms are provided "as is" and no implied or express warranties have been made or are provided as to their suitability for aplanning can vary over time and from place to place. All wills should be reviewed by a lawyer before they are signed. If the Testator moves to another state, the current will should be checked by a lalls for distribution in percentages, make sure that the total of all of the beneficiary's percentage's equal 100%. Check the totals before signing the Will. State and federal laws which affect estate use dies. The Will may be invalid if a spouse receives nothing or only a small portion of the estate. Consult an attorney if you wish to disinherit a spouse or any children. If any part of the Will cator's marital status changes, if the Testator has a child or if a named beneficiary or one of the Executors dies.. Most state laws guarantee a minimum share of an estate to a spouse when the other spo disregarded. Instead when changes are desired, the original and all copies should be destroyed and an entirely new Will should be signed. New wills are commonly necessary when, for example, the Testashould be discussed with a competent tax advisor. If it becomes necessary to change the Will, do not modify it by adding, deleting, or modifying words on the face of the Will. Such changes are usuallyerned by a will. This Will is not designed to reduce taxes. Estate taxes, if any, are based on the size of the total taxable estate and other matters. The tax results of the choices made in this Will rvivorship or property held in trust. In addition, the distribution of retirement plan benefits, life insurance proceeds and survivor benefits arising in other contracts and plans are not normally govthe death of the Testator, would automatically pass to another person by operation of law or by any contract. For example, the Will does not dispose of property held in joint tenancy with rights of su of the Will should be kept by the Testator and may also (if Testator so wishes) be provided to the person named as Executor / Personal Representative. This Will does not dispose of property that, on are prepared, only one original "copy" of a will should be prepared. While photocopies may used for reference purposes, only the original can be admitted to probate. Copies are rarely accepted. A copy & Instructions ­ Page 4 The original of the Will should be kept in a secure location such as a safe deposit box at a bank or lawyer's office. Unlike other legal instruments where multiple originals before naming them as a Personal Representative, to make sure that they are willing and can serve. If you select a bank or trust company, be sure to check into their fees for such services. Checklist to pick a person (or bank or trust company) that can be trusted to handle financial matters and to deal appropriately with family members. It is best to talk to people (and banks or trust companies) uding i.e. not counting the self-proving affidavit) should be entered by hand in the bottom right of each page. The Personal Representative / Executor, should be picked carefully. It is very importanttary or other person authorized to take acknowledgments and administer oaths. The affidavit states that all required formalities were observed when the Will was signed. The total number of pages (exclroving affidavit (called "Proof of Will" in some states) and attach it to the end of the Will. The Affidavit contains the Testator's acknowledgment and the affidavit of the witnesses, made before a Nohe Witnesses. The page with the self-proving affidavit, if included, should not be counted because the affidavit is not a part of the Will itself. The Testator and the witnesses should sign the self-pthe Will at a later date (i.e. if this Will revokes an earlier Will). The total number of pages in the Will, including the page(s) on which the witness signature lines appear, should be indicated by tning the Will freely and willingly. Wherever requested, the date should be filled in (preferably by hand), with the date of the actual signing. This step could be crucial to determine the validity of l witnesses must sign their names in the presence of the Testator and each other and of the notary public. The witnesses must be satisfied that the Testator is an adult of sound mind and he/she is sig good idea for the Testator to initial the bottom of each page of the Will. This can prevent subsequent substitution of pages. The witnesses should also initial the bottom of each page of the Will. Al example, the Testator can say: "The document I am about to sign is my Last Will and Testament. I am signing it freely and voluntarily", or similar words. Although not required in most states, it is ad orally declare that the document that is about to be signed, is intended to be the Testator's Last Will and Testament. However, the witnesses don't need to read or know the contents of the Will. Fornot be witnesses. All witnesses and the notary should watch the Testator/Testatrix sign the Will. The notary public is needed for the self proved affidavit. Before signing the Will, the Testator shoul is deemed to be invalid for any reason or if one of the witnesses can't be located. The witnesses should not be beneficiaries under the Will. For example children, spouses, heirs or executors should d and adult witnesses and a notary public. Important Note: Vermont requires three witnesses. The signature of a third witness can provide additional protection if the signature of one of the witnesses Checklist & Instructions ­ Page 3 Although most states only require two witnesses, the Will should be signed by the Testator/Testatrix in the presence of three (3) qualified, competent, disinterestey means that the Testator knows that he/she is signing a Will, is familiar with the property and the value thereof and knows about relatives and others who might be entitled to a share of the estate. · The Testator/Testatrix (i.e. the person who is writing the Will) must be of "sound mind" when signing the Will and must be of legal age (i.e. eighteen in most states). Being of "sound mind" usuallyland, California and the District of Columbia, the courts have some latitude to accept a will as self proved, to require an affidavit of the witnesses or to require the witnesses to testify. · · · ·ding the affidavit in those states will not invalidate the Will (since it is a separate document from the Will). In those states it will have to be "proven" in court, like any other Will. In Ohio, MarOhio and Vermont (as of 2003).do not have specific statutes permitting self proving wills. The affidavit will be of no use in those states and does not need to be completed. However, signing and inclu Will was signed. The Affidavit needs to be completed and signed , by the Testator/Testatrix, all Witnesses and a Notary in front of each other. Important Note: A few states like Louisiana, Maryland, r of pages; [] name of testator; []witness signatures and info Affidavit: The enclosed Affidavit (although technically not part of the Will) states that all required formalities were observed when theeous death of both husband and wife. Signature Block: Testator needs to fill out: [] day month year city; []Signature; []name Witnesses: Witnesses must provide and fill out: [] name of state; [] numbe matters like taxes, taking care of the property, and making distributions to the beneficiaries Article VII: Contains miscellaneous provisions including a provision dealing with situations of simultan the beneficiaries named in the will. Testator must provide and fill out [] the name of executor; [] name of alternate executor. Article VI: Powers of Executor empowers the representative to deal withalso responsible for paying outstanding debts, administration expenses and taxes out of the testator's estate. After paying debts and expenses, the Personal Representative will pay whatever is left toate, and an alternate in case the first choice cannot serve. The Executor will have the responsibility (after the testator's death) of managing the testator's property. The Personal Representative is laws the will is made · Article V: Deals with the appointment of the Testator's Personal Representative (i.e. Executor) and alternate; It allows the Testator to name an Executor to administer the estist & Instructions ­ Page 2 Residuary Estate is given to; [] name of beneficiary or beneficiaries to whom the residuary estate is given in event Spouse does not survive Testator; [] state under whoseen to (three blank paragraphs are provided, but you can add as many as you need). [] name of Spouse to whom Testator's interest in any primary residence is given; [] name of Spouse to whom the Checklecific dollar amounts or other property to specific persons or charities. Testator must provide and fill out: [] description of property (or dollar amount); [] name(s) of person/entity property is giv of funeral and Burial expenses. Article III: Authorizes payments of debts and expenses. Article IV: Disposes of specific property, primary residence and residuary property. Allows Testator to give spvide and fill out: []name, [] county and []state Article I: Gives the name of the spouse. Testator/Testatrix must provide and fill out [] name of spouse (in two places); Article II: Authorizes payment · · · · · · Title: Enter name of Testator/Testatrix in blank space under title "Last Will and Testament of". Introduction: Contains preliminary information about the will. Testator/Testatrix must proious sections. The content of each section is explained below. Some sections require information to be provided and filled out in the space provided. The enclosed Affidavit also needs to be completed.lls are the same. The Wills can be executed at different times although it is suggested (plus for practical purposes) that both Wills be executes/signed at the same time. This Will is divided into vares a self-proved affidavit. There are two Wills in this form package. The first Will and Affidavit is to be used by the Husband. The second Will is to be used by the Wife. The instructions for both wigo to other beneficiary(ies). This Will also allows the Testator/Testatrix to make specific gifts to others as well. This Will is suitable for estates worth less than $1,000,000. This Will also includ also has a provision dealing with situations of simultaneous death of both husband and wife. If the Spouse does not survive the Testator/Testatrix (i.e. man or woman making the will) the assets will ains two "Mutual Wills" and is for use by a married couple (husband and wife) with no children. The Wills distribute the assets of the Husband to the Wife and the assets of the Wife to the Husband. Itlls; (3) Husband's Mutual Will ­ Married Couple with No Children with self-proved affidavit; (4) Wife's Mutual Will ­ Married Couple with No Children with self-proved affidavit. This form package contChecklist and Instructions Mutual Will - Married Couple with No Children This package contains (1) Checklist and Instruction for Mutual Will ­ Married Couple with No Children; (2) Information about Wi OhioOhio ___________ Quitclaim Deed - 2 y ___________________________________________ _______________________________ Signature of Notary Public _______________________________ Printed Name of Notary My commission expires: _________________________________________ _____________________________ State of OHIO County of __________________________ ) ) ) ss The foregoing instrument was acknowledged before me on ______________________ b_______________________________ (Grantor's Spouse's Signature ­ if applicable) Quitclaim Deed - 1 Grantee's Address: _____________________________ _____________________________ Grantors Address: __ases all rights of dower therein (mark if applicable). EXECUTED this day of ________, 20 _______ . wife husband of the ____________________________________________ (Grantor' Signature) _____________ assigns shall have, claim or demand any right or title to the aforesaid property, premises or appurtenances or any part thereof. ____________________________ (Name of spouse of Grantor) Grantor, releproperty unto the said Grantee, Grantee's heirs, administrators, executors, successors and/or assigns forever; so that neither Grantor nor Grantor's heirs, administrators, executors, successors and/or_, State of Ohio with the following legal description: Prior Instrument Reference: Volume ____, Page ____ TO HAVE AND TO HOLD all of Grantor's right, title and interest in and to the above described ____________________________________________ all right, title, interest and claim to the following real property in the City of __________________________, County of ______________________________________ (address) ______________ County hereby REMISES, RELEASES, AND FOREVER QUITCLAIMS to ______________________________________________________ ("Grantee"), whose tax-mailing address is ______________ consideration, the receipt and sufficiency of which is hereby acknowledged, the undersigned, _________________________________________ ("Grantor"), married unmarried of ______________________________his deed and tax statements to: Above reserved for official use only QUITCLAIM DEED FOR A VALUABLE CONSIDERATION, in the amount of TEN AND NO/100 DOLLARS ($10.00) in hand and other good and valuabledocument with another party. The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Recording requested by: and when recorded, please return tbstitute for legal advice. These forms should only be a starting point for you and should not be used without consulting with an attorney first. An Attorney should be consulted before negotiating any yer taking a Quitclaim Deed, make sure that it satisfies your needs. Consult a real estate attorney and title insurance company to protect your interests. These forms are not intended and are not a su Deed as the only form of conveyance when buying a property. Quitclaim deeds are mainly used in family situations or to correct possible technical defects in the title to the property. If you are a buif any interest exists at all. This type of deed may be useful in cases where a party is unable to transfer a fee simple estate or make promises about the title. A buyer will rarely accept a Quitclaim used to convey an interest in real estate. A Quitclaim Deed does not include any promise or guarantee by the person making it (i.e. the Grantor) about the nature or quality of that interest, or even ument with another party. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Information for Quitclaim Deed This Quitclaim Deed form isitute for legal advice. These forms should only be a starting point for you and should not be used without consulting with an attorney first. An Attorney should be consulted before negotiating any docng on the type of document, additional requirements may apply. Nonconforming documents may be returned unrecorded or may be charged additional fees [_] These forms are not intended and are not a substthe legal description is correct. [_] A Quitclaim Deed may require other documents to be filed with it. Please check your local requirements with your local Recorder's (or similar) office. [_] Dependifective against third parties. Although witnesses are not required, it is generally a good idea to use them. [_] Documents referencing land should include a legal description of the land. Verify that uld date and sign the Quitclaim Deed before a Notary. Among other things, Notarization will allow the Quitclaim Deed to be recorded as a public record. Without filing, the Quitclaim Deed may not be efInstructions & Checklist for Quitclaim Deed [_] This package includes: (1) Instructions and Checklist for Quitclaim Deed, (2) Information for Quitclaim Deed, and (3) Quitclaim Deed [_] The Grantor sho OhioOhio : ______________________________ (Notary Public) 4 (s)he executed the same for the purposes expressed therein. I attest that the Declarant appears to be of sound mind and not under or subject to duress, fraud or undue influence. My Commission Expires____________________________________, (Name of Declarant) known to me or satisfactorily proven to be the Declarant whose name is subscribed to the above Living Will Declaration, and acknowledged that ENT State of Ohio County of _______________________________, S.S.: On this the ____________ day of _______________________, 20 _______, before me, the undersigned Notary Public, personally appeared _________________ (Witness 2 Signature) Print Name: ___________________________________ Address: ______________________________________ Date: _________________________________________ OR ACKNOWLEDGEM__ (Witness 1 Signature) Print Name: ___________________________________ Address: ______________________________________ Date: _________________________________________ _____________________________ministrator of a nursing home in which the Declarant is receiving care, and that I am an adult not related to the Declarant by blood, marriage, or adoption. ___________________________________________nd that the Declarant appears to be of sound mind and not under or subject to duress, fraud or undue influence. I further attest that I am not the attending physician of the Declarant, I am not the ad________________ (city), Ohio. __________________________________________ (Declarant's Signature) 3 I attest that the Declarant signed or acknowledged this Living Will Declaration in my presence, aience pain or suffering. I understand the purpose and effect of this document and sign my name to this Living Will Declaration after careful deliberation on _______________, (date) at ________________erized by both of the following: (1) I am irreversibly unaware of myself and my Environment, and (2) There is a total loss of cerebral cortical functioning, resulting in my having no capacity to experusness that, to a reasonable Degree of medical certainty as determined in Accordance with reasonable medical standards by My attending physician and one other physician who Has examined me, is charact no recovery, and (2) death is likely to occur within a relatively short time if life-sustaining treatment is not Administered. (c) "permanently unconscious state" means a state of Permanent unconscio of medical certainty as determined in Accordance with reasonable medical standards by my attending physician and one other physician who has examined me, both of the following apply: (1) there can beincipally to prolong the process of dying. (B) "terminal condition" means an irreversible, Incurable, and untreatable condition caused by Disease, illness, or injury from which, to a reasonable Degreening treatment" means any medical procedure, treatment, intervention, or other measure including artificially or technologically supplied nutrition and hydration that, when administered, will serve pr____________________________________________________________ Work Phone: _______________________________________________________________ For purposes of this Living Will Declaration: (A) "Life-sustai_______________________________ Address: __________________________________________________________________ ______________________________________ Zip Code: ___________________________ Home Phone: ___ Work Phone: _______________________________________________________________ Name 2: ____________________________________________________________________ Relationship: __________________________________________________________________________ ______________________________________ Zip Code: ___________________________ Home Phone: _______________________________________________________________ 2 of priority: Name 1: ____________________________________________________________________ Relationship: ______________________________________________________________ Address: _______________________es that life-sustaining treatment should be withheld or withdrawn, he or she shall make a good faith effort and use reasonable diligence to notify one of the persons named below in the following order ____________________________________________________________________________ ____________________________________________________________________________ In the event my attending physician determin______________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ MEDICAL STANDARDS, THAT SUCH NUTRITION OR HYDRATION WILL NOT OR NO LONGER WILL SERVE TO PROVIDE COMFORT TO ME OR ALLEVIATE MY PAIN. Additional Instructions (optional): ______________________________ERMANENTLY UNCONSCIOUS STATE AND IF MY ATTENDING PHYSICIAN AND AT LEAST ONE OTHER PHYSICIAN WHO HAS EXAMINED ME DETERMINE, TO A REASONABLE DEGREE OF MEDICAL CERTAINTY AND IN ACCORDANCE WITH REASONABLEE MY ATTENDING PHYSICIAN TO WITHHOLD,OR IN THE EVENT THAT TREATMENT HAS ALREADY COMMENCED, TO WITHDRAW THE PROVISION OF ARTIFICIALLY OR TECHNOLOGICALLY SUPPLIED NUTRITION AND HYDRATION, IF I AM IN A Pake me comfortable and to relieve my pain but not to postpone my death. o __________ IN ADDITION, IF I HAVE MARKED THE FOREGOING BOX AND HAVE PLACED MY INITIALS ON THE LINE ADJACENTTO IT, I AUTHORIZragraph, I have authorized its withholding or withdrawal; · withdraw such treatment if such treatment has commenced; and, · permit me to die naturally and provide me with only that care necessary to mhat my attending physician shall: 1 · administer no life-sustaining treatment, except for the provision of artificially or technologically supplied nutrition or hydration unless, in the following pally and provide me with only the care necessary to make me comfortable and to relieve my pain but not to postpone my death. In the event I am in a permanently unconscious state, I declare and direct tn, I declare and direct that my attending physician shall: · administer no life-sustaining treatment; · withdraw life-sustaining treatment if such treatment has commenced; and, permit me to die naturamedical or surgical treatment. I am a competent adult who understands and accepts the consequences of such refusal and the purpose and effect of this document. In the event I am in a terminal conditional condition or a permanently unconscious state, it is my intention that this Living Will Declaration shall be honored by my family and physicians as the final expression of my legal right to refuse vised Code, do voluntarily make known my desire that my dying shall not be artificially prolonged. If I am unable to give directions regarding the use of life-sustaining treatment when I am in a termi_____________________, (address) Ohio, being of sound mind and not subject to duress, fraud or undue influence, intending to create a Living Will Declaration under Chapter 2133 et. Seq. of the Ohio ReDurable Power of Attorney for Health Care. Declaration I, ___________________________________________________________, (name of Declarant) presently residing at _______________________________________ may be relied on only for individuals in a terminal condition or a permanently unconscious state. If you wish to direct your medical treatment in other circumstances, you should consider preparing a ning treatment, you have the legal right to so choose and you might want to state your medical treatment preferences in writing in another form of Declaration. Under Ohio law a Living Will Declaration withdrawn if the individual is unable to communicate and is in a terminal condition or a permanently unconscious state. If you would choose not to withhold or withdraw any or all forms of life sustaieclaration is designed to serve as evidence of an individual's desire that life-sustaining medical treatment, including artificially or technologically supplied nutrition and hydration, be withheld orofessional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Living Will DECLARATION Notice to Declarant This form of a Living Will Dar situation. Advice from a local attorney is always recommended when dealing with estate planning matters. Any possible tax consequences arising out of this document should be discussed with a tax pr 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 make sure it fits your particule 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 legal and/or tax advice. Laws varyed in this section, "DNR identification" has the same meaning as in section 2133.21 of the Revised Code. [_] These forms are provided "as is" and no implied or express warranties have been made or arny other type of designation, except that the printed form may be used as a DNR identification if the declarant specifies on the form that the declarant wishes to use it as a DNR identification. As us that life-sustaining treatment would be withheld or withdrawn pursuant to the declaration. The printed form shall not be used as an instrument for granting any other type of authority or for making aPage 5 state as described in division (A)(3)(a) of section 2133.02 of the Revised Code, and may designate one or more persons who are to be notified by the declarant's attending physician at any timer a permanently unconscious state, may authorize the withholding or withdrawal of nutrition or hydration should the declarant be in a permanently unconscious Living Will Information & Instructions ­ e use or continuation, or the withholding or withdrawal, of life-sustaining treatment should the declarant be in a terminal condition, a permanently unconscious state, or either a terminal condition oed form of a declaration ma y be sold or otherwise distributed in this state for use by adults who are not advised by an attorney. By use of a printed form of that nature, a declarant may authorize thing physician or other health care personnel acting under the direction of the attending physician shall make the fact a part of the declarant's medical record. § 2133.07 Use of printed form. A printnce with the revocation. (B) Upon the communication as described in division (A) of this section to the attending physician of a declarant of the fact that his declaration has been revoked, the attendontrary, the attending physician of a declarant and other health care personnel who are informed of the revocation of a declaration by an alleged witness may rely on the information and act in accordasician of the declarant by the declarant himself, a witness to the revocation, or other health care personnel to whom the revocation is communicated by such a witness. Absent actual knowledge to the c intention to revoke the declaration, except that, if the declarant made his attending physician aware of the declaration, the revocation shall be effective upon its communication to the attending phy04 of the Revised Code. § 2133.04 Revocation of declaration. (A) A declarant may revoke a declaration at any time and in any manner. The revocation shall be effective when the declarant expresses histhe declarant should be in a terminal condition or in a permanently unconscious state. Division (B)(2) of this section does not apply if the declarant revokes the declaration pursuant to section 2133.ower of attorney for health care and a valid declaration, the declaration supersedes the durable power of attorney for health care to the extent that the provisions of the documents would conflict if ate order, as defined in section 2133.21 of the Revised Code, that a physician has issued for the declarant and that is inconsistent with the declaration. (2) If a declarant has both a valid durable p a DNR identification, as defined in section 2133.21 of the Revised Code, of the declarant that is based upon a prior inconsistent declaration of the declarant or that is based upon a do- not-resuscit(1)(a) of this section does not apply if a declaration is revoked pursuant to section 2133.04 of the Revised Code after the signing of a general consent to treatment form. (b) A declaration supersedesion, or the withholding or withdrawal, of life-sustaining treatment and other medical or nursing procedures, treatments, interventions, or other measures in connection with the declarant. Division (B) extent that the provisions of a declaration and a general consent to treatment form do not conflict, both documents shall govern the use Living Will Information & Instructions ­ Page 4 or continuater the declarant's admission to a health care facility to the extent there is a conflict between the declaration and the form, even if the form is signed after the execution of the declaration. To thesions regarding the administration of life-sustaining treatment. (B)(1)(a) A declaration supersedes any general consent to treatment form signed by or on behalf of the declarant prior to, upon, or afta reasonable degree of medical certainty, and in accordance with reasonable medical standards, that there is no reasonable possibility that the declarant will regain the capacity to make informed decion to become operative in connection with a declarant who is in a terminal condition or in a permanently unconscious state, the attending physician of the declarant shall determine, in good faith, to acquired in the practice of medicine or surgery or osteopathic medicine and surgery, is qualified to determine whether the declarant is in a permanently unconscious state. (3) In order for a declaratianches of medicine or surgery or osteopathic medicine and surgery, of certification as a specialist in a particular branch of medicine or surgery or osteopathic medicine and surgery, or of experience arant is in the permanently unconscious state shall be a physician who, by virtue of advanced education or training, of a practice limited to particular diseases, illnesses, injuries, therapies, or bre. (2) In order for a declaration to become operative in connection with a declarant who is in a permanently unconscious state, the consulting physician associated with the determination that the declen the declaration becomes operative, the attending physician and health care facilities shall act in accordance with its provisions or comply with the provisions of section 2133.10 of the Revised Cod (3) of this section are satisfied, and the attending physician determines that the declarant no longer is able to make informed decisions regarding the administration of life-sustaining treatment. Wh declarant determine that the declarant is in a terminal condition or in a permanently unconscious state, whichever is addressed in the declaration, the applicable requirements of divisions (A)(2) and attorney for health care . (A)(1) A declaration becomes operative when it is communicated to the attending physician of the declarant, the attending physician and one other physician who examines thes the same meaning as in section 2133.21 of the Revised Code. § 2133.03 When declaration becomes operative; declaration supersedes general consent to treatment, DNR identification or durable power ofhas become operative as described in division (A) of section 2133.03 of the Revised Code, shall comply with the provisions of section 2133.10 of the Revised Code. (E) As used in this section, "CPR" haliance with the declarant's declaration, the physician or facility promptly shall so advise the declarant and comply with the provisions of section 2133.10 of the Revised Code, or, if the declaration ing Will Information & Instructions ­ Page 3 (2) If an attending physician of a declarant or a health care facility in which a declarant is confined is not willing or not able to comply or allow compf an attending physician of a declarant or of a health care facility in which a declarant is confined may refuse to comply with the declarant's declaration on the basis of a matter of conscience. Live facility in which a declarant is confined may refuse to comply or allow compliance with the declarant's declaration on the basis of a matter of conscience or on another basis. An employee or agent od, when section 2133.05 of the Revised Code is applicable, also shall comply with that section. (D)(1) Subject to division (D)(2) of this section, an attending physician of a declarant or a health carnding physician, or other health care personnel acting under the direction of an attending physician, who is furnished a copy of a declaration shall make it a part of the declarant's medical record anfication described in section 147.53 of the Revised Code and also shall attest that the declarant appears to be of sound mind and not under or subject to duress, fraud, or undue influence. (C) An atteed to appear on the same page of the declaration. (2) If acknowledged for purposes of division (A) of this section, a declaration shall be acknowledged before a notary public, who shall make the certiud, or undue influence. The signatures of the declarant or other individual at the direction of the declarant under division (A) of this section and of the witnesses under this division are not require declarant or other individual at the direction of the declarant and, by doing so, attest to the witness' belief that the declarant appears to be of sound mind and not under or subject to duress, frahysician of the declarant, and who are not the administrator of any nursing home in which the declarant is receiving care. Each witness shall subscribe the witness' signature after the signature of ththe direction of the declarant, signed the declaration. The witnesses to a declaration shall be adults who are not related to the declarant by blood, marriage, or adoption, who are not the attending pIf witnessed for purposes of divisio n (A) of this section, a declaration shall be witnessed by two individuals as described in this division in whose presence the declarant, or another individual at hen a declarant is in a terminal condition. The provisions of division (E) of section 2133.12 of the Revised Code pertaining to comfort care shall apply to a declarant in a terminal condition. (B)(1) in division (A)(3)(a)(i) of this section. (b) Division (A)(3)(a) of this section does not apply to the extent that a declaration authorizes the withholding or withdrawal of life-sustaining treatment w that is adjacent to a similar statement on a printed form of a declaration; (ii) Placing the declarant's initials or signature underneath or adjacent to the statement, check, or other mark described le medical standards, that nutrition or hydration will not or no longer will serve to provide comfort to the declarant or alleviate the declarant's pain, or checking or otherwise marking a box or line state and if the declarant's attending physician and at least one other physician who has examined the declarant determine, to a reasonable degree of medical certainty and in accordance with reasonabdface type, that the declarant's attending Living Will Information & Instructions ­ Page 2 physician may withhold or withdraw nutrition and hydration if the declarant is in a permanently unconsciousus state by doing both of the following in the declaration: (i) Including a statement in capital letters or other conspicuous type, including, but not limited to, a different font, bigger type, or bolalleviate the declarant's pain, then the declarant shall authorize the declarant's attending physician to withhold or withdraw nutrition or hydration when the declarant is in the permanently unconscior withdraw nutrition or hydration when the declarant is in a permanently unconscious state and when the nutrition and hydration will not or no longer will serve to provide comfort to the declarant or of section 2133.01 of the Revised Code. (3)(a) If a declarant who has authorized the withholding or withdrawal of life-sustaining treatment intends that the declarant's attending physician withhold o either or both of the terms "terminal condition" and "permanently unconscious state" and shall define or otherwise explain those terms in a manner that is substantially consistent with the provisions to apply when the declarant is in a terminal condition, in a permanently unconscious state, or in either a terminal condition or a permanently unconscious state, the declarant's declaration shall usethe withholding or withdrawal of CPR in accordance with sections 2133.01 to 2133.15 or sections 2133.21 to 2133.26 of the Revised Code. (2) Depending upon whether the declarant intends the declarationcific authorization for the use or continuation or the withholding or withdrawal of CPR, but the failure to include a specific authorization for the withholding or withdrawal of CPR does not preclude s who are to be notified by the declarant's attending physician at any time that life-sustaining treatment would be withheld or withdrawn pursuant to the declaration. The declaration may include a spedivision (B)(1) of this section or be acknowledged by the declarant in accordance with division (B)(2) of this section. The declaration may include a designation by the declarant of one or more persontment. The declaration shall be signed at the end by the declarant or by another individual at the direction of the declarant, state the date of its execution, and either be witnessed as described in ; refusal to comply. (A)(1) An adult who is of sound mind voluntarily may execute at any time a declaration governing the use or continuation, or the withholding or withdrawal, of life-sustaining treavenience, we have included useful excerpts from the Ohio Statutes relating to Living Wills. 2133.02 Declaration governing use or continuation, or withholding or withdrawal, of lifesustaining treatmentains (1) Information and Instruction for Ohio Living Will; (2) Ohio Living Will. This Ohio Living Will is based on Title 21 Chapter 2133 Section 2133.01 et. Seq. of the Ohio Revised Code. For your con duress, fraud or undue influence. My Commission Expires:____________________ _________________________________________ (Notary) -9- Information and Instructions Ohio Living Will This package cont for Health Care as the principal, and acknowledged that (s)he executed the same for the purposes expressed therein. I attest that the principal appears to be of sound mind and not under or subject toPublic, personally appeared ______________________________________, who is known to me or who has satisfactorily proven to be the person whose name is subscribed to the above Durable Power of Attorney______________ -8- OR ACKNOWLEDGEMENT State of Ohio County of _____________________________, s.s.: On this the _________ day of _________________________, 20___, before me, the undersigned Notary ______________________ Print Name: ___________________________________________________ Residence Address: _____________________________________________ Date: ______________________________________________________________________ Residence Address: _____________________________________________ Date: ________________________________________________________ Witness Signature: _______________________eceiving care, and that I am an adult not related to the principal by blood, marriage or adoption. Witness Signature: _____________________________________________ Print Name: _______________________uence. I further attest that I am not the agent designated in this document, I am not the attending physician of the principal, I am not the administrator of a nursing home in which the principal is re principal signed or acknowledged this Durable Power of Attorney for Health Care in my presence, that the principal appears to be of sound mind and not under or subject to duress, fraud or undue inflALID UNLESS IT IS EITHER (1) SIGNED BY TWO ELIGIBLE WITNESSES AS DEFINED BELOW WHO ARE PRESENT WHEN YOU SIGN OR ACKNOWLEDGE YOUR SIGNATURE OR (2) ACKNOWLEDGED BEFORE A NOTARY PUBLIC. I attest that theration on _________________________ (date) at ____________________________, (city) Ohio. ___________________________________ (Principal) THIS DURABLE POWER OF ATTORNEY FOR HEALTH CARE WILL NOT BE Vary public or two witnesses who meet the law's requirements. I understand the purpose and effect of this document and sign my name to this Durable Power of Attorney for Health Care after careful delibthe notice printed at the end of this document. I have read this notice before signing this document. I understand that this document will not be valid unless I sign it in the presence of either a nottness -7- to the revocation. I understand that if I execute a new durable power of attorney for health care, the new document will automatically replace this one. Ohio law requires that I be given of this document to a physician, my revocation will not be effective as to that physician until the fact of my revocation is communicated to that physician (or the physician's staff) by me or by a wiTHIS DOCUMENT I understand that I can revoke this document at any time and in any manner merely by expressing my intention to revoke it. This can be done verbally or in writing. If I have given a copyalth care decisions. 8. PRIOR DESIGNATIONS REVOKED. I hereby revoke any prior Durable Powers of Attorney for Health Care executed by me under Chapter 1337 of the Ohio Revised Code. 9. REVOCATION OF date. 7. SEVERABILITY. Any invalid or unenforceable power, authority or provision of this instrument shall not affect any other power, authority or provision or the appointment of my agent to make he NO EXPIRATION DATE. This Durable Power of Attorney for Health Care shall not be affected by my disability or by lapse of time. This Durable Power of Attorney for Health Care shall have no expiration ________________________ (address) _________________ (home telephone number) _________________ (work telephone number) Each alternate shall have and exercise all of the authority conferred above. 6._ (home telephone number) _________________ (work telephone number) Second Alternate Agent___________________________________________,(name and relationship) presently residing at ____________________tinue to serve: First Alternate Agent: ___________________________________________,(name and relationship) presently residing at ____________________________________________ (address) ________________thorities and to serve under this instrument, in the order named, if at any time the agent first named (or any alternate designee) is not readily available or is unwilling or unable to serve or to conATE AGENT. -6- Because I wish that an agent shall be available to exercise the authorities granted hereunder at all times, I further designate each of the following individuals to succeed to such auERTAINTY AND IN ACCORDANCE WITH REASONABLE MEDICAL STANDARDS, THAT SUCH NUTRITION OR HYDRATION WILL NOT OR NO LONGER WILL SERVE TO PROVIDE COMFORT TO ME OR ALLEVIATE MY PAIN. 5. DESIGNATION OF ALTERNED NUTRITION AND HYDRATION IF I AM IN A PERMANENTLY UNCONSCIOUS STATE AND IF MY ATTENDING PHYSICIAN AND AT LEAST ONE OTHER PHYSICIAN WHO HAS EXAMINED ME DETERMINES, TO A REASONABLE DEGREE OF MEDICAL CLACED MY INITIALS ON THE LINE ADJACENT TO IT, MY AGENT MAY REFUSE, OR IN THE EVENT TREATMENT HAS ALREADY COMMENCED, WITHDRAW INFORMED CONSENT TO THE PROVISION OF ARTIFICIALLY OR TECHNOLOGICALLY SUPPLIions that my agent is authorized to make pursuant to this document. 4. WITHDRAWAL OF NUTRITION AND HYDRATION WHEN IN A PERMANENTLY UNCONSCIOUS STATE. ? IF I HAVE MARKED THE FOREGOING BOX AND HAVE Pferred to another facility; (2) Documents that are Do Not Resuscitate Orders, Discharge Orders or other similar orders; and (3) Any other document necessary or desirable to implement health care decissisted residence facilities, and the like; and (h) To execute on my behalf any or all of the following: (1) Documents that are written consents to medical treatment or written requests that I be transealth care, as my agent shall determine to be appropriate; (g) To select and contract with any medical or health care facility on my behalf, including, but not limited to, hospitals, nursing homes, asn if necessary; (f ) To select, employ, and discharge health care personnel, such as physicians, nurses, therapists and other medical professionals, including individuals and services providing home hcare facility records; (d) To execute on my behalf any releases or other documents that may be required in order to obtain this information; (e) To consent to the further disclosure of this informatio withdrawal in Paragraph 4; (c) To request, review, and receive any information, verbal or written, regarding my physical or mental health, including, but not limited to, all of my medical and health d, however, my agent is not authorized to refuse or direct the withdrawal of -5- artificially or technologically supplied nutrition or hydration unless I have specifically authorized such refusal orration; (b) If I am in a permanently unconscious state, to give informed consent to life-sustaining treatment or to withdraw or to refuse to give informed consent to life-sustaining treatment; providem in a terminal condition, to give, to withdraw or to refuse to give informed consent to life-sustaining treatment, including the provision of artificially or technologically supplied nutrition or hydy or desirable to implement the health care decisions that my agent is authorized to make pursuant to this document, my agent has the power and authority to do any and all of the following: (a) If I ament or otherwise made known to my agent by me or, if I have not made my desires known, that are, in the judgment of my agent, in my best interests. 3. ADDITIONAL AUTHORITIES OF AGENT. Where necessar used to maintain, diagnose or treat my physical or mental condition. In exercising this authority, my agent shall make health care decisions that are consistent with my desires as stated in this docuth care decisions for myself. My agent shall have the authority to give, to withdraw or to refuse to give informed consent to any medical or nursing procedure, treatment, intervention or other measuredecisions for me to the same extent that I could make such decisions for myself if I had the capacity to do so, at any time during which I do not have the capacity to make or communicate informed healdocument or, if not expressed here, as otherwise made known to my agent by me.. 2. GENERAL STATEMENT OF AUTHORITY GRANTED. I hereby grant to my agent full power and authority to make all health care (home telephone number) _________________ (work telephone number) as my attorney in fact who shall act as my agent to make health care decisions for me consistent with my wishes as authorized in this e and appoint: ________________________________________________________________ (name of agent) presently residing at _____________________________________________________ (address) _________________ am an adult of sound mind. After careful consideration, I knowingly and voluntarily create this Durable Power of Attorney for Health Care under Chapter 1337 of the Ohio Revised Code, I hereby designatESIGNATION OF attorney in fact. I, _____________________________________________________________, (name) presently residing at _______________________________________________________, (address) Ohio, are also are ineligible to be witnesses. If there is anything in this document that you do not understand, you should ask your lawyer to explain it to you. -4- Power of Attorney for Health Care 1. DNo person who is related to you by blood, marriage, or adoption may be a witness. The attorney in fact, your attending physician, and the administrator of any nursing home in which you are receiving c a durable power of attorney for health care unless it is acknowledged before a notary public or is signed by at least two adult witnesses who are present when you sign or acknowledge your signature. orney for health care with it, it will revoke any prior, valid durable power of attorney for health care that you created, unless you indicate otherwise in this document. This document is not valid asor other health care personnel to whom the revocation is communicated by such a witness communicate it to your attending physician. If you execute this document and create a valid durable power of attwever, if you made your attending physician aware of this document, any such revocation will be effective only when you communicate it to your attending physician, or when a witness to the revocation attorney in fact and the right to revoke this entire document at any time and in any manner. Any such revocation generally will be effective when you express your intention to make the revocation. Ho power it grants to your attorney in fact will continue in effect until you regain the capacity to make informed health care decisions for yourself. You have the right to revoke the designation of therney for health care generally will expire. However, if you specify an expiration date and then lack the capacity to make informed health care decisions for yourself on that date, the document and the you and the employee or agent are members of the same religious order. This document has no expiration date under Ohio law, but yo u may choose to specify a date upon which your durable power of attonder this document, unless either type of employee or agent is a competent adult and related to you by blood, marriage, or adoption, or unless either type of employee or agent is a competent adult andcument. Additionally, you CANNOT designate an employee or agent of your attending physician, or an employee or agent of a health care facility at which you are being treated, as the attorney in fact uorney in fact under this document. However, you CANNOT designate your attending physician or the administrator of any nursing home in which you are receiving care as the attorney in fact under this dolth care records, and to consent to the disclosure of health care records. You can limit that right in this document if you so choose. -3- Generally, you may designate any competent adult as the attn fact in another manner. When acting pursuant to this document, the attorney in fact GENERALLY will have the same rights that you have to receive information about proposed health care, to review headesires or, if your desires are unknown, to act in your best interest. You may express your desires to the attorney in fact by including them in this document or by making them known to the attorney i achieving the purposes for which you consented to its use. Additionally, when exercising authority to make health care decisions for you, the attorney in fact will have to act consistently with your consented, unless a change in your physical condition has significantly decreased the benefit of that health care to you, or unless the health care is not, or is no longer, significantly effective in HYDRATION TO YOU IF YOU ARE IN A PERMANENTLY UNCONSCIOUS STATE BY COMPLYING WITH THE REQUIREMENTS OF (4)(C)(I) AND (II) ABOVE. (5) Withdraw informed consent to any health care to which you previouslyTHER MARK PREVIOUSLY DESCRIBED. (D) YOUR ATTENDING PHYSICIAN DETERMINES, IN GOOD FAITH, THAT YOU AUTHORIZED THE ATTORNEY IN FACT TO REFUSE OR WITHDRAW INFORMED CONSENT TO THE PROVISION OF NUTRITION ORCKING OR OTHERWISE MARKING A BOX OR LINE (IF ANY) THAT IS ADJACENT TO A SIMILAR STATEMENT ON THIS DOCUMENT; (II) PLACING YOUR INITIALS OR SIGNATURE UNDERNEATH OR ADJACENT TO THE STATEMENT, CHECK, OR OYOU IF YOU ARE IN A PERMANENTLY UNCONSCIOUS STATE AND IF THE DETERMINATION THAT NUTRITION OR HYDRATION WILL NOT OR NO LONGER WILL SERVE TO PROVIDE COMFORT TO YOU OR ALLEVIATE YOUR PAIN IS MADE, OR CHES TYPE, INCLUDING, BUT NOT LIMITED TO, A DIFFERENT FONT, BIGGER TYPE, OR BOLDFACE TYPE, THAT THE ATTORNEY IN FACT MAY REFUSE OR WITHDRAW INFORMED CONSENT TO THE PROVISION OF NUTRITION OR HYDRATION TO REFUSE OR WITHDRAW INFORMED CONSENT TO THE PROVISION OF NUTRITION OR HYDRATION TO YOU BY DOING BOTH OF THE FOLLOWING IN THIS DOCUMENT: (I) INCLUDING A STATEMENT IN CAPITAL LETTERS OR OTHER CONSPICUOUYDRATION WILL NOT OR -2- NO LONGER WILL SERVE TO PROVIDE COMFORT TO YOU OR ALLEVIATE YOUR PAIN. (C) IF, BUT ONLY IF, YOU ARE IN A PERMANENTLY UNCONSCIOUS STATE, YOU AUTHORIZE THE ATTORNEY IN FACT TOTTENDING PHYSICIAN AND AT LEAST ONE OTHER PHYSICIAN WHO HAS EXAMINED YOU DETERMINE, TO A REASONABLE DEGREE OF MEDICAL CERTAINTY AND IN ACCORDANCE WITH REASONABLE MEDICAL STANDARDS, THAT NUTRITION OR HISION OF ARTIFICIALLY OR TECHNOLOGICALLY ADMINISTERED SUSTENANCE (NUTRITION) OR FLUIDS (HYDRATION) TO YOU, UNLESS: (A) YOU ARE IN A TERMINAL CONDITION OR IN A PERMANENTLY UNCONSCIOUS STATE. (B) YOUR Adetermine, to a reasonable degree of medical certainty and in accordance with reasonable medical standards, that the fetus would not be born alive); (4) REFUSE OR WITHDRAW INFORMED CONSENT TO THE PROVwal would terminate the pregnancy (unless the pregnancy or health care would pose a substantial risk to your life, or unless your attending physician and at least one other physician who examines you ITHDRAW INFORMED CONSENT TO THE PROCEDURE, TREATMENT, INTERVENTION, OR OTHER MEASURE.); (3) Refuse or withdraw informed consent to health care for you if you are pregnant and if the refusal or withdra, INTERVENTION, OR OTHER MEASURE WILL NOT OR NO LONGER WILL SERVE TO PROVIDE COMFORT TO YOU OR ALLEVIATE YOUR PAIN, THEN, SUBJECT TO (4) BELOW, YOUR ATTORNEY IN FACT WOULD BE AUTHORIZED TO REFUSE OR WE TAKEN TO DIMINISH YOUR PAIN OR DISCOMFORT, NOT TO POSTPONE YOUR DEATH. CONSEQUENTLY, IF YOUR ATTENDING PHYSICIAN WERE TO DETERMINE THAT A PREVIOUSLY DESCRIBED MEDICAL OR NURSING PROCEDURE, TREATMENTLUIDS (HYDRATION) WHEN ADMINISTERED TO DIMINISH YOUR PAIN OR DISCOMFORT, NOT TO POSTPONE YOUR DEATH, AND ANY OTHER MEDICAL OR NURS ING PROCEDURE, TREATMENT, INTERVENTION, OR OTHER MEASURE THAT WOULD Bion or hydration to you as described under (4) below). (YOU SHOULD UNDERS TAND THAT COMFORT CARE IS DEFINED IN OHIO LAW TO MEAN ARTIFICIALLY OR TECHNOLOGICALLY ADMINISTERED SUSTENANCE (NUTRITION) OR Fe you with comfort care (except that, if the attorney in fact is not prohibited from doing so under (4) below, the attorney in fact could refuse or withdraw informed consent to the provision of nutritat there is no reasonable possibility that you will regain the capacity to make informed health care decisions for yourself); (2) Refuse or withdraw informed consent to health care necessary to providg no capacity to experience pain or suffering, and your attending physician additionally determines, to a reasonable degree of medical certainty and in accordance with reasonable medical standards, thstate of permanent unconsciousness that is characterized by you being irreversibly unaware of yourself and your environment and by a total loss of cerebral cortical functioning, resulting in you havin in accordance with reasonable medical standards, that there is no reasonable possibility that you will regain the capacity to make informed health care decisions for yourself. -1- (b) You are in a s likely to occur within a relatively short time if life-sustaining treatment is not administered, and your attending physician additionally determines, to a reasonable degree of medical certainty and following applies: (a) You are suffering from an irreversible, incurable, and untreatable condition caused by disease, illness, or injury from which (i) there can be no recovery and (ii) your death i(unless your attending physician and one other physician who examines you determine, to a reasonable degree of medical certainty and in accordance with reasonable medical standards, that either of the make health care decisions for you under this document, the attorney in fact NEVER will be authorized to do any of the following: (1) Refuse or withdraw informed consent to life-sustaining treatment o withdraw informed consent to any care, treatment, service, or procedure to maintain, diagnose, or treat a physical or mental condition. HOWEVER, even if the attorney in fact has general authority toe capacity to do so. The authority of the attorney in fact to make health care decisions for you GENERALLY will include the authority to give informed consent, to refuse to give informed consent, or tealth care matter, the attorney in fact GENERALLY will be authorized by this document to make health care decisions for you to the same extent as you could make those decisions yourself, if you had thlth care decisions for you. Subject to any specific limitations you include in this document, if your attending physician determines that you have lost the capacity to make an informed decision on a hrself, you retain the right to make all medical and other health care decisions for yourself. You may include specific limitations in this document on the authority of the attorney in fact to make hea that you have lost the capacity to make informed health care decisions for yourself and, notwithstanding this document, as long as you have the capacity to make informed health care decisions for youthe power to make MOST health care decisions for you if you lose the capacity to make informed health care decisions for yourself. This power is effective only when your attending physician determinesNT (Pursuant to R.C. Sec.1337.17) This is an important legal document. Before executing this document, you should know these facts: This document gives the person you designate (the attorney in fact) [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com -6- Durable Power of Attorney for Health Care NOTICE TO ADULT EXECUTING THIS DOCUMEion. You should also consult an attorne y whenever a document is negotiated with another party. Any possible tax consequences arising out of this document should be discussed with a tax professional. point for you and should not be used without consulting with an attorney first. Before using or signing this document you should have an attorney review it to make sure it fits your particular situateffect 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 only be a startingtype, or boldface type. [_] These forms are provided "as is" and no implied or express warranties have been made or are provided as to their suitability for any specific purpose or as to their legal paragraph (2), followed by an asterisk and all of paragraph (4) shall appear in the printed form in capital letters or other conspicuous type, including, but not limited to, a different font, bigger on shall include the following notice (see notice below at the beginning of the Power of Attorney): In the preceding notice, the single words, and the two sentences in the second set of parentheses inted form shall not be used as an instrument for granting authority for any other decisions. Any printed form that is sold or otherwise distributed in this state for the purpose described in this sectifor use by adults who are not advised by an attorney. By use of such a printed form, a principal may authorize an attorney in fact to make health care decisions on the principal's behalf, but the prin power of attorney for health care. § 1337.17 Use of printed form; notice to principal. A printed form of durable power of attorney for health care may be sold or otherwise distributed in this state g physician shall make the fact a part of the principal's medical record. (C) Unless the instrument provides otherwise, a valid durable power of attorney for health care revokes a prior, valid durablesician of a principal of the fact that his durable power of attorney for health care has been revoked, the attending physician or other health care personnel acting under the direction of the attendinlth care by an alleged witness may rely on the information and act in accordance with the revocation. -5- (B) Upon the communication as described in division (A) of this section to the attending phyh a witness. Absent actual knowledge to the contrary, the attending physician of the principal and other health care personnel who are informed of the revocation of a durable power of attorney for heashall be effective upon its communication to the attending physician by the principal himself, a witness to the revocation, or other health care personnel to whom the revocation is communicated by sucbe effective when the principal expresses his intention to so revoke, except that, if the principal made his attending physician aware of the durable power of attorney for health care, the revocation rable power of attorney for health care may revoke that instrument or the designation of the attorney in fact under it. The principal may so revoke at any time and in any manner. The revocation shall lth care is not, or is no longer, significantly effective in achieving the purposes for which the principal consented to its use. § 1337.14 Revocation of power. (A) A principal who creates a valid dunsented, unless at least one of the following applies: (1) A change in the physical condition of the principal has significantly decreased the benefit of that health care to the principal. (2) The hea of this section. (F) An attorney in fact under a durable power of attorney for health care does not have authority to withdraw informed consent to any health care to which the principal previously co informed consent to the provision of nutrition or hydration to the principal when the principal is in a permanently unconscious state by complying with the requirements of divisions (E)(2)(a) and (b)ion. (3) If the principal is in a permanently unconscious state, the principal's attending physician determines, in good faith, that the principal authorized the attorney in fact to refuse or withdraw durable power of attorney for health care; (b) Placing the principal's initials or signature underneath or adjacent to the statement, check, or other mark described in division (E)(2)(a) of this sectcious state and if the determination described in division (E)(1) of this section is made, or checking or otherwise marking a box or line that is adjacent to a similar statement on a printed form of abigger type, or boldface type, that the attorney in fact may refuse or withdraw informed consent to the provision of nutrition or hydration to the principal if the principal is in a permanently uncons doing both of the following in the durable power of attorney for health care: (a) Including a statement in capital letters or other conspicuous type, including, but not limited to, a different font, has authorized the attorney in fact to refuse or withdraw informed consent to the provision of nutrition or -4- hydration to the principal when the principal is in a permanently unconscious state byrds, that nutrition or hydration will not or no longer will serve to provide comfort to, or alleviate pain of, the principal. (2) If the principal is in a permanently unconscious state, the principal principal's attending physician and at least one other physician who has examined the principal determine, to a reasonable degree of medical certainty and in accordance with reasonable medical standaormed consent to the provision of nutrition or hydration to the principal, unless the principal is in a terminal condition or in a permanently unconscious state and unless the following apply: (1) Thee with reasonable medical standards, that the fetus would not be born alive. (E) An attorney in fact under a durable power of attorney for health care does not have authority to refuse or withdraw inf of the principal, or unless the principal's attending physician and at least one other physician who has examined the principal determine, to a reasonable degree of medical certainty and in accordancth care for a principal who is pregnant if the refusal or withdrawal of the health care would terminate the pregnancy, unless the pregnancy or the health care would pose a substantial risk to the life provision of nutrition or hydration to the principal. (D) An attorney in fact under a durable power of attorney for health care does not have authority to refuse or withdraw informed consent to healn or hydration to the principal if, under the circumstances described in division (E) of this section, the attorney in fact would not be prohibited from refusing or withdrawing informed consent to thenot preclude, and shall not be construed as precluding, an attorney in fact under a durable power of attorney for health care from refusing or withdrawing informed consent to the provision of nutritioable power of attorney for health care does not have authority, on behalf of the principal, to refuse or withdraw informed consent to health care necessary to provide comfort care. This division does ble possibility that the principal will regain the capacity to make informed health care decisions for the principal. (C) Except as otherwise provided in this division, an attorney in fact under a durate, the attending physician of the principal shall determine, in good faith, to a reasonable degree of medical certainty, and in accordance with reasonable medical standards, that there is no reasonascious state. (3) In order for an attorney in fact to refuse or withdraw informed consent to life-sustaining treatment for a principal who is in a terminal condition or in a permanently unconscious stc medicine and surgery, or of experience acquired in the practice of medicine and surgery or osteopathic medicine and surgery, is qualified to determine whether the principal is in a permanently uncons, illnesses, injuries, therapies, or branches of medicine and surgery or osteopathic medicine and surgery, of certification as a specialist in a particular branch of medicine or surgery or osteopathith the determination that the principal is in the permanently -3- unconscious state shall be a physician who, by virtue of advanced education or training, of a practice limited to particular disease) In order for an attorney in fact to refuse or withdraw informed consent to life-sustaining treatment for a principal who is in a permanently unconscious state, the consulting physician associated wing treatment, unless the principal is in a terminal condition or in a permanently unconscious state and unless the applicable requirements of divisions (B)(2) and (3) of this section are satisfied. (2 care records. (B) (1) An attorney in fact under a durable power of attorney for health care does not have authority, on behalf of the principal, to refuse or withdraw informed consent to lifesustainito the instrument, the attorney in fact has the same right as the principal to receive information about proposed health care, to review health care records, and to consent to the disclosure of healthtrument, to make or participate in the making of health care decisions on behalf of the principal. (3) Unless the right is limited in a durable power of attorney for health care, when acting pursuant s section does not affect, and shall not be construed as affecting, any right that the person designated as attorney in fact in a durable power of attorney for health care may have, apart from the ins that authority, the attorney in fact shall act consistently with the desires of the principal or, if the desires of the principal are unknown, shall act in the best interest of the principal. (2) Thiame extent as the principal could make those decisions for the principal if the principal had the capacity to do so. Except as otherwise provided in divisions (B) to (F) of this section, in exercising as otherwise provided in divisions (B) to (F) of this section and subject to any specific limitations in the instrument, the attorney in fact may make health care decisions for the principal to the se decisions for the principal, and only if the attending physician of the principal determines that the principal has lost the capacity to make informed health care decisions for the principal. Except make health care decisions for the principal only if the instrument substantially complies with section 1337.12 of the Revised Code and specifically authorizes the attorney in fact to make health carication" have the same meanings as in section 2133.21 of the Revised Code. § 1337.13 Authority of attorney in fact. (A) (1) An attorney in fact under a durable power of attorney for health care shall power of attorney. (2) As used in division (D) of this section: -2- (a) "Declaration" has the same meaning as in section 2133.01 of the Revised Code. (b) "Do-not-resuscitate order" and "DNR identif do-not-resuscitate order that a physician issued for the principal which is inconsistent with the durable power of attorney for health care or a valid decision by the attorney in fact under a durablees the durable power of attorney for health care to the extent of any conflict between the two. A valid durable power of attorney for health care supersedes any DNR identification that is based upon aased upon a valid declaration and if the declaration supersedes the durable power of attorney for health care under division (B) of section 2133.03 of the Revised Code, the DNR identification supersed care and a valid declaration, division (B) of section 2133.03 of the Revised Code applies. If a principal has both a valid durable power of attorney for health care and a DNR identification that is bshall attest that the principal appears to be of sound mind and not under or sub ject to duress, fraud, or undue influence. (D) (1) If a principal has both a valid durable power of attorney for healthb) of this section, a durable power of attorney for health care shall be acknowledged before a notary public, who shall make the certification described in section 147.53 of the Revised Code and also due influence. The signatures of the principal and the witnesses under this division are not required to appear on the same page of the instrument. (C) If acknowledged for purposes of division (A)(1)(itness's signature after the signature of the principal and, by doing so, attest to the witness's belief that the principal appears to be of sound mind and not under or subject to duress, fraud, or un for health care shall involve the principal signing, or acknowledging the principal's signature, at the end of the instrument in the presence of each witness. Then, each witness shall subscribe the we attending physician of the principal, and the administrator of any nursing home in which the principal is receiving care are ineligible to be witnesses. The witnessing of a durable power of attorneyt ineligible to be witnesses under this division. Any person who is related to the principal by blood, marriage, or adoption, any person who is designated as the attorney in fact in the instrument, thprincipal. (B) If witnessed for purposes of division (A)(1)(b) of this section, a durable power of attorney for health care shall be witnessed by at least two individuals who are adults and who are nonformed health care decisions for the principal on the expiration date, the instrument shall continue in effect until the principal regains the capacity to make informed health care decisions for the ll not expire, unless the principal specifies an expiration date in the instrument. However, when a durable power of attorney contains an expiration date, if the principal lacks the capacity to make imarriage, or adoption, or if the -1- individual is a competent adult and the principal and the individual are members of the same religious order. (3) A durable power of attorney for health care shatations do not preclude a principal from designating either type of employee or agent as the principal's attorney in fact if the individual is a competent adult and related to the principal by blood, n which the principal is being treated shall not be designated as an attorney in fact in, or act as an attorney in fact pursuant to, a durable power of attorney for health care, except that these limias an attorney in fact pursuant to, a durable power of attorney for health care. An employee or agent of the attending physician of the principal and an employee or agent of any health care facility i attorney in fact. The attending physician of the principal and an administrator of any nursing home in which the principal is receiving care shall not be designated as an attorney in fact in, or act y the principal in accordance with division (C) of this section. (2) Except as otherwise provided in this division, a durable power of attorney for health care may designate any competent adult as the shall be signed at the end of the instrument by the principal and shall state the date of its execution. (b) It shall be witnessed in accordance with division (B) of this section or be acknowledged bormed consent to any health care that is being or could be provided to the principal. Additionally, to be valid, a durable power of attorney for health care shall satisfy both of the following: (a) Iterwise provided in divisions (B) to (F) of section 1337.13 of the Revised Code, the authorization may include the right to give informed consent, to refuse to give informed consent, or to withdraw inf for the principal at any time that the attending physician of the principal determines that the principal has lost the capacity to make informed health care decisions for the principal. Except as othr of attorney, in accordance with division (B) of section 1337.09 of the Revised Code, that authorizes an attorney in fact as described in division (A)(2) of this section to make health care decisionspower of attorney for health care; witnesses; acknowledgment. (A) (1) An adult who is of sound mind voluntarily may create a valid durable power of attorney for health care by executing a durable powen Ohio Statutes Title 13 Chapter 1337 Section 1337.11 et. Seq. The following are useful excerpts from the Ohio Statutes relating to the Ohio Power of Attorney for Health Care Form. § 1337.12 Durable is package contains (1) Information and Instruction for Ohio Power of Attorne y for Health Care; (2) Ohio Power of Attorney for Health Care Form. This Ohio Power of Attorney for Health Care is based oprofessional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Information and Instructions Ohio Power of Attorney for Health Care Thular situation. Advice from a local attorney is always recommended when dealing with estate planning matters. Any possible tax consequences arising out of this document should be discussed with a tax ry 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 make sure it fits your particare 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 legal and/or tax advice. Laws vaDirective. The first form is the Power of Attorney for Health Care and the second form is the Living Will. [_] These forms are provided "as is" and no implied or express warranties have been made or Ohio Advance Health Care Directive This package contains both a Ohio Power of Attorney for Health Care and a Ohio Living Will. Together these forms are also sometimes known as an Advance Health Care OhioOhio _____________ 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 Ohio