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Pennsylvania contingency has occurred, is conclusive proof of the nonrevocation or nontermination of the power at that time and conclusive proof that the specified time or contingency has occurred. -7- knowledge of the termination of the power by revocation, death or, if applicable, disability or incapacity or the filing of an action in divorce and that, if applicable, the specified future time or _________________ Date -6- 20 Pa.C.S.A. Section 5606 states that an affidavit executed by the agent under a power of attorney stating that he did not have at the time of exercise of the power actualle caution and prudence. I shall keep a full and accurate record of all actions, receipts and disbursements on behalf of the principal. ______________________________ Signature of Agent ______________attorney or in 20 Pa.C.S. when I act as agent: I shall exercise the powers for the benefit of the principal. I shall keep the assets of the principal separate from my assets. I shall exercise reasonab the attached power of attorney and am the person identified as the alternate Agent for the Principal. I hereby acknowledge that in the absence of a specific provision to the contrary in the power of ehalf of the principal. ______________________________ Signature of Agent _______________________________ Date -5- Acknowledgment by Alternate Agent I, ___________________________________, have readhall keep the assets of the principal separate from my assets. I shall exercise reasonable caution and prudence. I shall keep a full and accurate record of all actions, receipts and disbursements on backnowledge that in the absence of a specific provision to the contrary in the power of attorney or in 20 Pa.C.S. when I act as agent: I shall exercise the powers for the benefit of the principal. I srinted, or stamped -4- Acknowledgment by Agent I, ___________________________________, have read the attached power of attorney and am the person identified as the Agent for the Principal. I hereby roduced ________________________________ as identification. _________________________________ Signature of person taking acknowledgment (Notary Public) _________________________________ Name typed, p_____ ) The foregoing instrument was acknowledged before me this _____ day of ____________________, ______ by __________________________ (name of Principal), who is personally known to me or who has p_______________ Name: ___________________________________ City: __________________________________ State: ___________________________________ State of PENNSYLVANIA ) ) ss County of _____________________________________________________ Name: ___________________________________ City: __________________________________ State: ___________________________________ Witness Signature: ____________________y providing written notice to my Agent. Signed on ________________ (date), at _______________________ (city), Pennsylvania. ________________________________ Signature of Principal Witness Signature: _able for breach of fiduciary duty, failure to act 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 bty of this document, without notice of such termination, shall be held harmless. -3- Agent shall not be liable for losses resulting from judgment errors made in good faith. However, Agent will be lis that arise against the third party because of reliance 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 authori act under it. Revocation of the power of attorney 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 claimny 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 appointment by my Agent. Any third party who receives a copy of this document mayers granted to my Agent by this power-of-attorney 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 atial invalidity. No person needs to inquire as to 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 powent is held to be invalid, illegal or unenforceable 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 parPower of Attorney. The listing of specific terms, 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 documtive or fiduciary acting on my behalf, my Agent shall 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 of this Power of Attorney. If desired, my Agent shall also be entitled to reasonable compensation for any services provided as my Agent If so requested by myself or any authorized personal representaAttorney shall be valid notwithstanding the lapse of time since its execution. My Agent shall be entitled to reimbursement of all reasonable expenses incurred as a result of carrying out any provisiond evaluate information effectively, to communicate decisions, and/or to manage my financial resources and affairs properly, as certified in writing by a licensed medical doctor. This Durable Power of y subsequent disability, incapacity or lack of mental competence, except as provided by any applicable statute. As used herein, "disability" or "incapacity" shall mean a lack of capacity to receive ans, powers, and authority of this document shall remain in full force and effect thereafter until my death or recovery from any disability or incapacity. This Power of Attorney shall not terminate on mdy." This Durable Power of Attorney and all rights and powers therein shall become effective upon my subsequent disability or incapacity as certified in writing by a licensed medical doctor. The rightnterests in estates and trusts." 20. "To pursue claims and litigation." 21. "To receive government benefits." 22. "To pursue tax matters." -2- 23. "To make an anatomical gift of all or part of my boking and financial transactions." 15. "To borrow money." 16. "To enter safe deposit boxes." 17. "To engage in insurance transactions." 18. "To engage in retirement plan transactions." 19. "To handle i11. "To engage in tangible personal property transaction." 12. "To engage in stock, bond and other securities transactions." 13. "To engage in commodity and option transactions." 14. "To engage in banion to a medical, nursing, residential or similar facility and to enter into agreements for my care." 9. "To authorize medical and surgical procedures." 10. "To engage in real property transactions." hare of the estate of my deceased spouse." "To disclaim any interest in property." "To renounce fiduciary positions." "To withdraw and receive the income or corpus of a trust." "To authorize my admisslementation of power of attorney): 1. 2. 3. 4. 5. 6. 7. 8. "To make limited gifts." "To create a trust for my benefit." "To make additions to an existing trust for my benefit." "To claim an elective sower of attorney and the rights hereby granted. My Agent's powers and authority shall empower him (her) to do any or all of the following, each of which is defined in 20 Pa.C.S.A.5603 (relating to impr 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 virtue of this pbligation 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 intangible, or matte as my alternate or successor Agent, as necessary, to serve with the same powers, rights and discretions. My Agent shall have full power and authority to perform any act, power, duty, legal right or o my behalf. If the above named Agent is unable to serve for any reason, I appoint _____________________________________ maintaining an address at: _____________________________________________________nt ________________________________________ ("Agent") maintaining an address at: _____________________________________________________ my true and lawful attorney-in-fact for me and in my name, and in Date -1- KNOW ALL PERSONS BY THESE PRESENTS: I, ____________________________________ ("Principal") maintaining an address at _______________________________________________ do hereby make and appoiE THIS NOTICE AND I UNDERSTAND ITS CONTENTS. _________________________________ Signature of Principal / Grantor _________________________________ Name of Principal / Grantor __________________________D MORE FULLY IN 20 PA.C.S. CH. 56. IF THERE IS ANYTHING ABOUT THIS FORM THAT YOU DO NOT UNDERSTAND, YOU SHOULD ASK A LAWYER OF YOUR OWN CHOOSING TO EXPLAIN IT TO YOU. I HAVE READ OR HAD EXPLAINED TO MSEPARATE FROM YOUR AGEN'TS FUNDS. A COURT CAN TAKE AWAY THE POWERS OF YOUR AGENT IF IT FINDS YOUR AGENT IS NOT ACTING PROPERLY. THE POWERS AND DUTIES OF AN AGENT UNDER A POWER OF ATTORNEY ARE EXPLAINEE INCAPACITATED, UNLESS YOU EXPRESSLY LIMIT THE DURATION OF THESE POWERS OR YOU REVOKE THESE POWERS OR A COURT ACTING ON YOUR BEHALF TERMINATES YOUR AGENT'S AUTHORITY. YOUR AGENT MUST KEEP YOUR FUNDS RCISED, YOUR AGENT MUST USE DUE CARE TO ACT FOR YOUR BENEFIT AND IN ACCORDANCE WITH THIS POWER OF ATTORNEY. YOUR AGENT MAY EXERCISE THE POWERS GIVEN HERE THROUGHOUT YOUR LIFETIME, EVEN AFTER YOU BECOMSPOSE OF ANY REAL OR PERSONAL PROPERTY WITHOUT ADVANCE NOTICE TO YOU OR APPROVAL BY YOU. THIS POWER OF ATTORNEY DOES NOT IMPOSE A DUTY ON YOUR AGENT TO EXERCISE GRANTED POWERS, BUT WHEN POWERS ARE EXE TO PRINCIPAL / GRANTOR: THE PURPOSE OF THIS POWER OF ATTORNEY IS TO GIVE THE PERSON YOU DESIGNATE (YOUR "AGENT") BROAD POWERS TO HANDLE YOUR PROPERTY, WHICH MAY INCLUDE POWERS TO SELL OR OTHERWISE DIy accepting or acting under the appointment, the agent assumes the fiduciary and other legal responsibilities of an agent. -4- PENNSYLVANIA DURABLE POWER OF ATTORNEY Effective upon Disability NOTICEtain competent legal advice. This 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: Br dispose of your property. Any such 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, obocument, consider its consequences. 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 o packages offered for sale, generally include state specific instructions. -3- CAUTION! PRINCIPAL: The Powers granted by this power of attorney document are broad and sweeping. Before signing this dot intended as and is not a substitute for legal advice. Furthermore, this information is general information that is not state specific. Whenever appropriate, the instructions included with the formsable Power of Attorney be witnessed, it is always a very good idea to do so. Two witnesses are necessary, if the Agent will deal with any real estate in Florida. Please note that this information is nrd party to challenge 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 Durwer of Attorney should 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 thid or incompetent, an alternate Agent can be designated, at the time this Power of Attorney is signed, in the event the original Agent is unable to serve or continue to serve as the Agent. A Durable Poo effect, or the Agent undertakes the acts. The Principal can revoke a Durable Power of Attorney at any time. Since this Durable Power of Attorney takes effect only after the Principal becomes disablegent, within the scope of the Power of Attorney document, will be legally binding upon the Principal. This is especially important if the Principal is incapacitated when the Power of Attorney goes into be a lawyer. Almost anyone can be appointed an attorney-in-fact by a power of attorney. A Power of Attorney is a "powerful" instrument and should be granted with care. Any action undertaken by the Afective upon the disability or incapacity of the Principal. 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 tpal" or "Principal") to authorize someone else (called the "Agent" or "AttorneyIn-Fact") to act on his or her behalf, even if the Principal later becomes incapacitated. This particular Form becomes efs of Use found at findlegalforms.com -2- Information Durable Power of Attorney Effective upon Disability A Durable Power of Attorney allows a natural "mentally competent " person (called the "Princiout consulting with an attorney first. An Attorney should be consulted before negotiating a document with another party. [_] The purchase and use of these forms, is subject to the Disclaimers and Termialed) or the words "no one" can be entered. [_] These forms are not intended and are not a substitute for legal advice. These forms should only be a starting point for you and should not be used withment offers the option of nominating an alternate Agent in the event that the first choice as Agent is unable to serve or continue to serve as the Agent. This section can be removed, deleted (and init selection of the Agent. The powers 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. -1- [_] This docutransactions he undertakes. [_] The 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 Agent should have access to the original document as needed. The Agent could also have an original document (i.e. with original signatures). The Agent should be prepared to make copies for different gent at the bottom of the Power of Attorney document. The Alternate Agent will have the same powers and duties as the Agent. [_] The Principal should keep the original document, as well as a copy. Thence. The Agent shall keep a full and accurate record of all actions, receipts and disbursements on behalf of the Principal. [_] The alternate Agent will have to sign the Acknowledgement of Alternate Aent shall exercise the powers for the benefit of the Principal. The Agent shall keep separate the assets of the Principal from those of the Agent. The Agent shall exercise reasonable caution and prudemust also sign the "Notice to Principal" at the beginning of the Power of Attorney document. [_].The Agent will have to sign the Acknowledgement at the bottom of the Power of Attorney document. The Aglthough not necessary, signing the document before a Notary is suggested. Notarization will also allow the Durable Power of Attorney to be recorded as a public record, if necessary. [_] The Principal e individual who signed the power of attorney on behalf of and at the direction of the principal. Furthermore, witnesses should not be related by blood or marriage to the Principal, Agent or Notary. As incapable of signing) or by another individual (at the direction of the Principal), then it shall be witnessed by two individuals, each of whom is 18 years of age or older. A witness shall not be thity of the Principal. [_] The Principal (i.e. the person granting the power of Attorney) must be mentally competent. In Pennsylvania, if the Power of Attorney is executed by mark (when the Principal i; (2) Information for Durable Power of Attorney Effective upon Disability; (3) Durable Power of Attorney Effective upon Disability [_] This Durable Power of Attorney becomes effective upon the DisabilInstructions & Checklist Pennsylvania Durable Power of Attorney Effective upon Disability [_] This package contains (1) Instructions & Checklist for Durable Power of Attorney Effective upon Disability PennsylvaniaPennsylvania of which the person(s) acted, executed the instrument. WITNESS my hand and official seal. Signature __________________________________ (Seal) t and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf________________________________ ___________, personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrumen__________ before me, (here insert name and title of the officer), personally appeared ________________________________________________________________________ ________________________________________________ Names of institutions/individuals who have been provided a copy of this revocation: Notary Acknowledgment State of __________________________ County of ________________________ ) ) ss ) On ______ State:_________________________ Witness Signature:__________________ Date: ___________________________ Name: ___________________________ City: _________________________ State:_________________ ___________________ (date). _____________________________ Principal Witness Signature:__________________ Date: ___________________________ Name: ___________________________ City: ___________________ artificial life sustaining procedures is revoked and withdrawn and this document provides notice of such revocation. IN WITNESS WHEREOF, I have signed this Health Care Power of Attorney Revocation on______________________________ (title of document(s)) dated __________________ and all power and authority granted thereby including powers for making health care decisions on my behalf and concerningRevocation I, ___________________________________ (Principal) maintaining an address at __________________________________________________ (address of Principal), hereby revoke my ____________________ion that is not state specific. Whenever appropriate, the instructions included with the forms packages offered for sale, generally include state specific instructions. Health Care Power of Attorney revoked. This revocation becomes effective immediately. Please note that this information is not intended as and is not a substitute for legal advice. Furthermore, this information is general informate Power of Attorney Revocation is used by the Grantor to give notice that a previously granted Health Care Power of Attorney (sometimes referred to as a Living Will or Health Care Directive) has been alth Care Power of Attorney Revocation If the Grantor of a Health Care Power of Attorney decides to revoke the document, it is almost always required that the revocation be in writing. The Health Carfor you and should not be used without consulting with an attorney first. The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Information Hetify both. These forms are not intended and are not a substitute for legal advice. Laws are different from state to state and may change from time to time. These forms should only be a starting point e revocation document. If more than one document is being revoked, then each document needs to be identified i.e. if you are revoking a Health Care Power of Attorney and a Living Will, be sure to idenpies of the Health Care Power of Attorney so as to avoid any questions about the revocation or its effectiveness. The exact full title of the document(s) that you are revoking should be inserted in thon. In the event the original power of attorney was filed publicly (i.e. recorded), then the notice of revocation should also be filed publicly, in the same manner. The Principal should destroy any coceived a copy of the original Power of Attorney or who may have dealt with the Agent acting on behalf of the Principal. It is a good idea to keep a record of anyone who was sent a copy of the revocatio the Principal, the Agent or the Notary should not be a witness. The Principal should keep a copy of the revocation in his/her files. Copies of the revocation should be sent to anyone who may have reough not always required, it is always a good idea to also have two witnesses sign the Revocation of Power of Attorney. The witnesses should be adults. Generally, anyone related by blood or marriage tified mail receipt, delivery receipt etc..). Any health care providers need to be given a copy of the Revocation as well and copies of the revocation should be kept in any relevant medical files. Alth show that it was the Grantor's intent to revoke the Power of Attorney. If possible, the Principal should keep a copy of any document showing that the Agent received the original revocation (i.e. certd. Notarization is also necessary to record the revocation. This revocation becomes effective immediately. The original or a copy of the revocation must be given to the Agent (i.e. Attorney-inFact) tohe Health Care Power of Attorney Revocation before a Notary even if it is not required. Notarization will also help to ensure that the revocation is effective and support its authenticity if challengeer of Attorney Revocation (3) Health Care Power of Attorney Revocation The Principal (i.e. the person granting the Health Care Power of Attorney Revocation; sometimes called the Grantor) should sign tInstructions & Checklist Health Care Power of Attorney Revocation This package includes (1) Checklist & Instructions for Health Care Power of Attorney Revocation (2) Information about Health Care Pow PennsylvaniaPennsylvania _____________________________________ Witness's address: ______________________________________________ -3- by signature or mark in my presence. Witness's signature: ____________________________________________ Witness's address: ______________________________________________ Witness's signature: ______________ Declarant's address: ____________________________________________ The declarant, or the person on behalf of and at the direction of the declarant, knowingly and voluntarily signed this writingt. Other instructions (or write none): -2- I made this declaration on the _________________ day of _________________. (day) (month, year) Declarant's signature: ____________________________________ey dialysis. I do I do do not want antibiotics. I realize that if I do not specifically indicate my preference regarding any of the forms of treatment listed above, I may receive that form of treatmenartificial or invasive form of I do nutrition (food) or hydration (water). I do do not want blood or blood products. I do do not want any form of surgery or invasive diagnostic tests. do not want kidncribed above, I feel especially strongly about the following forms of treatment: I do do not want cardiac resuscitation. I do do not want mechanical respiration. do not want tube feeding or any other e limited to measures to keep me comfortable and to relieve pain, including any pain that might occur by withholding or withdrawing life-sustaining treatment. In addition, if I am in the condition des or withdraw life-sustaining treatment that serves only to prolong the process of my dying, if I should be in a terminal condition or in a state of permanent unconsciousness. I direct that treatment b I become incompetent. This declaration reflects my firm and settled commitment to refuse life-sustaining treatment under the circumstances indicated below. I direct my attending physician to withhold_________ Date -1- Pennsylvania Living Will Declaration I, ___________________________________________________, being of sound mind, willfully and voluntarily make this declaration to be followed ifINED TO ME THIS NOTICE AND I UNDERSTAND ITS CONTENTS. _________________________________ Signature of Principal / Grantor _________________________________ Name of Principal / Grantor _________________Pennsylvania Living Will Declaration NOTICE IF THERE IS ANYTHING ABOUT THIS FORM THAT YOU DO NOT UNDERSTAND, YOU SHOULD ASK A LAWYER OF YOUR OWN CHOOSING TO EXPLAIN IT TO YOU. I HAVE READ OR HAD EXPLAuences arising out of this document should be discussed with a tax professional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com 2 you should have an attorney review it to make sure it fits your particular situation. You should also consult an attorney whenever a document is negotiated with another party. Any possible tax conseqy from time to time and from state to state. These forms should only be a starting point for you and should not be used without consulting with an attorney first. Before using or signing this documentre 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 varttorney, all powers of attorney shall be durable as provided in section 5604 (durable powers of attorney). [_] These forms are provided "as is" and no implied or express warranties have been made or a person designated by a principal in a power of attorney to act on behalf of that principal. 1 § 5601.1. Powers of attorney presumed durable. Unless specifically provided otherwise in the power of aonable caution and prudence. · Keep a full and accurate record of all actions, receipts and disbursements on behalf of the principal. (f) Definition.--As used in this chapter, the term "agent" means af attorney, the fiduciary relationship includes the duty to: · Exercise the powers for the benefit of the principal. · Keep separate the assets of the principal from those of an agent. · Exercise reas is proper. e) Fiduciary relationship.--An agent acting under a power of attorney has a fiduciary relationship with the principal. In the absence of a specific provision to the contrary in the power oce of a signed notice, upon a challenge to the authority of an agent to exercise a power under a power of attorney, the agent shall have the burden of demonstrating that the exercise of this authorityrincipal. (c) Notice.--All powers of attorney shall include the following notice in capital letters at the beginning of the power of attorney. The notice shall be signed by the principal. In the absenen it shall be witnessed by two individuals, each of whom is 18 years of age or older. A witness shall not be the individual who signed the power of attorney on behalf of and at the direction of the pl be signed and dated by the principal by signature or mark, or by another on behalf of and at the direction of the principal. If the power of attorney is executed by mark or by another individual, th writing to an agent and, unless the power of attorney expressly directs to the contrary, shall be construed in accordance with the provisions of this chapter. (b) Execution.--A power of attorney shalral rule.--In addition to all other powers that may be delegated to an agent, any or all of the powers referred to in section 5602(a) (relating to form of power of attorney) may lawfully be granted inbased in part on the Pennsylvania Statutes at 20 PA.C.S. CH. 56. The following are useful excerpts from the Statutes relating to the Pennsylvania Declaration Form. § 5601. General provisions. (a) Geneation including excerpts from the Pennsylvania Statutes relating to the Pennsylvania Declaration Form; (2) Pennsylvania Living Will Declaration Form. This Pennsylvania Living Will Declaration Form is Pennsylvania Living Will Information The Pennsylvania Living Will Declaration Form is for use in Pennsylvania. This package contains (1) Information and Instruction for Pennsylvania Living Will Declar PennsylvaniaPennsylvania n behalf of the principal. ___________________________________ Signature of Substitute Agent / Surrogate _______________________________ Date -5- I shall keep the assets of the principal separate from my assets. I shall exercise reasonable caution and prudence. I shall keep a full and accurate record of all actions, receipts and disbursements oby acknowledge that in the absence of a specific provision to the contrary in the power of attorney or in 20 Pa.C.S. when I act as agent: I shall exercise the powers for the benefit of the principal. antially the following form I, ___________________________________, have read the attached power of attorney and am the person identified as the Substitute Agent / Surrogate for the Principal. I here (Substitute Surrogate) An agent shall have no authority to act as agent under the power of attorney unless the agent has first executed and affixed to the power of attorney an acknowledgment in substns, receipts and disbursements on behalf of the principal. ______________________________ Signature of Agent / Surrogate _______________________________ Date -4- Acknowledgment by Substitute Agentr the benefit of the principal. I shall keep the assets of the principal separate from my assets. I shall exercise reasonable caution and prudence. I shall keep a full and accurate record of all actiorogate for the Principal. I hereby acknowledge that in the absence of a specific provision to the contrary in the power of attorney or in 20 Pa.C.S. when I act as agent: I shall exercise the powers foower of attorney an acknowledgment in substantially the following form I, ___________________________________, have read the attached power of attorney and am the person identified as the Agent / Suress: ___________________ -3- Acknowledgment by Agent (Surrogate) An agent shall have no authority to act as agent under the power of attorney unless the agent has first executed and affixed to the parily signed this writing by signature or mark in my presence. Witness's signature: __________________ Witness's signature: __________________ Witness's address: ___________________ Witness's addr______________________________ Declarant's address: ____________________________________________ The declarant, or the person on behalf of and at the direction of the declarant, knowingly and voluntevent of my disability.. Other instructions (or write none): I made this declaration on the _________________ day of _________________. (day) (month, year) -2- Declarant's signature: _____________my attending physician and a second physician or licensed clinical psychologist after a personal examination of me and shall be certified in writing. This advance directive shall not terminate in the way. My surrogate t's authority hereunder is effective as long as I am incapable of making an informed decision. The determination that I am incapable of making an informed decision shall be made by ational evaluation of the risks and benefits of a proposed medical decision as compared with the risks and benefits of alternatives to that decision, or unable to communicate such understanding in anyng medical treatment. The phrase "incapable of making an informed decision" means unable to understand the nature, extent and probable consequences of a proposed medical decision or unable to make a ramed above, full power and authority to make health care decisions on my behalf whenever I have been determined to be incapable of making an informed decision about providing, withholding or withdrawi_______________________________________ Address: ______________________________________________________ Phone: _______________________________________________________ I hereby grant to my surrogate, n_____________________ Phone: _______________________________________________________ Name and address of substitute surrogate (if surrogate designated above is unable to serve): Name: ________________and in a terminal condition or in a state of permanent unconsciousness. The surrogate shall be: Name: _______________________________________________________ Address: _________________________________ and voluntarily make this declaration to be followed if I become incompetent. I want to designate another person as my surrogate to make medical treatment decisions for me if I should be incompetent Name of Principal / Grantor __________________________ Date -1- Pennsylvania Power of Attorney for Health Care I, ___________________________________________________, being of sound mind, willfullyTO EXPLAIN IT TO YOU. I HAVE READ OR HAD EXPLAINED TO ME THIS NOTICE AND I UNDERSTAND ITS CONTENTS. _________________________________ Signature of Principal / Grantor _________________________________TIES OF AN AGENT UNDER A POWER OF ATTORNEY ARE EXPLAINED MORE FULLY IN 20 PA.C.S. CH. 56. IF THERE IS ANYTHING ABOUT THIS FORM THAT YOU DO NOT UNDERSTAND, YOU SHOULD ASK A LAWYER OF YOUR OWN CHOOSING OUR AGENT'S AUTHORITY. YOUR AGENT MUST KEEP YOUR FUNDS SEPARATE FROM YOUR AGEN'TS FUNDS. A COURT CAN TAKE AWAY THE POWERS OF YOUR AGENT IF IT FINDS YOUR AGENT IS NOT ACTING PROPERLY. THE POWERS AND DUVEN HERE THROUGHOUT YOUR LIFETIME, EVEN AFTER YOU BECOME INCAPACITATED, UNLESS YOU EXPRESSLY LIMIT THE DURATION OF THESE POWERS OR YOU REVOKE THESE POWERS OR A COURT ACTING ON YOUR BEHALF TERMINATES YENT TO EXERCISE GRANTED POWERS, BUT WHEN POWERS ARE EXERCISED, YOUR AGENT MUST USE DUE CARE TO ACT FOR YOUR BENEFIT AND IN ACCORDANCE WITH THIS POWER OF ATTORNEY. YOUR AGENT MAY EXERCISE THE POWERS GIPERTY, WHICH MAY INCLUDE POWERS TO SELL OR OTHERWISE DISPOSE OF ANY REAL OR PERSONAL PROPERTY WITHOUT ADVANCE NOTICE TO YOU OR APPROVAL BY YOU. THIS POWER OF ATTORNEY DOES NOT IMPOSE A DUTY ON YOUR AGrms of Use found at findlegalforms.com 2 Pennsylvania Power of Attorney for Health Care NOTICE THIS POWER OF ATTORNEY MAY GIVE THE PERSON YOU DESIGNATE (YOUR "AGENT") BROAD POWERS TO HANDLE YOUR PROwith another party. Any possible tax consequences arising out of this document should be discussed with a tax professional. [_] The purchase and use of these forms is subject to the Disclaimers and Terst. Before using or signing this document you should have an attorney review it to make sure it fits your particular situatio n. You should also consult an attorney whenever a document is negotiated tute for legal and/or tax advice. Laws vary from time to time and from state to state. These forms should only be a starting point for you and should not be used without consulting with an attorney fi or express warranties have been made or are provided as to their suitability for any specific purpose or as to their legal effect or completeness. [_]These forms are not intended and are not a substically provided otherwise in the power of attorney, all powers of attorney shall be durable as provided in section 5604 (durable powers of attorney). [_] These forms are provided "as is" and no implied in this chapter, the term "agent" means a person designated by a principal in a power of attorney to act on behalf of that principal. 1 § 5601.1. Powers of attorney presumed durable. Unless specifial from those of an agent. · Exercise reasonable caution and prudence. · Keep a full and accurate record of all actions, receipts and disbursements on behalf of the principal. (f) Definition.--As usedc provision to the contrary in the power of attorney, the fiduciary relationship includes the duty to: · Exercise the powers for the benefit of the principal. · Keep separate the assets of the principrating that the exercise of this authority is proper. e) Fiduciary relationship.--An agent acting under a power of attorney has a fiduciary relationship with the principal. In the absence of a specifil be signed by the principal. In the absence of a signed notice, upon a challenge to the authority of an agent to exercise a power under a power of attorney, the agent shall have the burden of demonston behalf of and at the direction of the principal. (c) Notice.--All powers of attorney shall include the following notice in capital letters at the beginning of the power of attorney. The notice shalcuted by mark or by another individual, then it shall be witnessed by two individuals, each of whom is 18 years of age or older. A witness shall not be the individual who signed the power of attorney . (b) Execution.--A power of attorney shall be signed and dated by the principal by signature or mark, or by another on behalf of and at the direction of the principal. If the power of attorney is exeer of attorney) may lawfully be granted in writing to an agent and, unless the power of attorney expressly directs to the contrary, shall be construed in accordance with the provisions of this chapterForm. § 5601. General provisions. (a) General rule.--In addition to all other powers that may be delegated to an agent, any or all of the powers referred to in section 5602(a) (relating to form of powania Power of Attorney for Health Care is based in part on the Pennsylvania Statutes at 20 PA.C.S. CH. 56. The following are useful excerpts from the Statutes relating to the Pennsylvania Declaration ower of Attorney for Health Care including excerpts from the Pennsylvania Statutes relating to the Pennsylvania Declaration Form; (2) Pennsylvania Power of Attorney for Health Care Form. This PennsylvInformation Pennsylvania Power of Attorney for Health Care The Pennsylvania Power of Attorney for Health Care is for use in Pennsylvania and contains (1) Information and Instruction for Pennsylvania P PennsylvaniaPennsylvania _________________ Name: _______________________________________________ Address: ____________________________________________ City: _______________________________________________ State: ______________________________: _______________________________________________ State: _______________________________________________ SECOND WITNESS: Date: __________________ Signature: ___________________________________________ITNESS: Date: __________________ Signature: ___________________________________________ Name: _______________________________________________ Address: ____________________________________________ Cityion and in the presence of the Donor and each other. The individual signing the Donation of Gift was directed to do so by the Donor and signed the document in his/her presence as well as ours. FIRST Wnd by two witnesses, all of whom have signed at the direction and in the presence of the donor and of each other, and state that it has been so signed.] Witness Statement: We have signed at the direct____________________ WITNESS FORM [An anatomical gift may be made only by a document of gift signed by the donor. If the donor cannot sign, the document of gift must be signed by another individual a_ Print your name: ______________________________________ Address: ____________________________________________ City: _______________________________________________ State: ___________________________n, surgeon, technician, or enucleator to carry out the appropriate procedures. SIGNATURE: (Sign and date the form here:) Date: __________________ Sign your name: _____________________________________the appropriate procedures. In the absence of a designation or if the designee is not available, the donee or other person authorized to accept the anatomical gift may employ or authorize any physiciaof the following you do not want): (1) Transplant (2) Therapy (3) Research (4) Education (Optional) I designate ___________________________________ as my particular physician or surgeon to carry out __ ________________________________________________________________________ ________________________________________________________________________ My gift is for the following purposes (strike any x): Give any needed organs, tissues, or parts, OR Give the following organs, tissues, or parts only: ____________________________ ______________________________________________________________________ for all serious legal matters. Anatomical Gift by Living Donor Pursuant to Uniform Anatomical Gift Act Upon my death, I ____________________________________ (the "Donor"), hereby (mark applicable boand on any theory of liability, whether in contract, strict liability, or tort (including negligence or otherwise) arising in any way out of the use of these materials. An attorney should be consultedntal, special, exemplary, or consequential damages (including, but not limited to, procurement of substitute goods or services; loss of use, data, or profits; or business interruption) however caused risk. In no event will: i) FindLegalForms, Inc, its agents, partners, or affiliates, or ii) the providers, authors or publishers of the forms, be responsible or liable for any direct, indirect, incideovided "AS-IS." We do not give any express or implied warranties of merchantability, suitability or completeness for any of the materials for your particular needs. The materials are used at your own erials. FindLegalForms, Inc. does not provide legal advice. The purchase and use of these materials is subject to the "Disclaimers and Terms of Use" found at findlegalforms.com. These materials are pran anatomical gift. During a terminal illness or injury, the refusal may be an oral statement or other form of communication. Disclaimer No Attorney-Client relationship is created by use of these matocument of gift, (ii) a statement attached to or imprinted on a donor's motor vehicle operator's or chauffeur's license, or (iii) any other writing used to identify the individual as refusing to make the consent or concurrence of any person after the donor's death. An individual may refuse to make an anatomical gift of the individual's body or part by (i) a writing signed in the same manner as a ddelivery of a signed statement to a specified donee to whom a document of gift had been delivered. An anatomical gift that is not revoked by the donor before death is irrevocable and does not require ) a signed statement; (2) an oral statement made in the presence of two individuals; (3) any form of communication during a terminal illness or injury addressed to a physician or surgeon; or (4) the f, after death, the will is declared invalid for testamentary purposes, the validity of the anatomical gift is unaffected. A donor may amend or revoke an anatomical gift, not made by will, only by: (1ze any physician, surgeon, technician, or enucleator to carry out the appropriate procedures. An anatomical gift by will takes effect upon death of the testator, whether or not the will is probated. In to carry out the appropriate procedures. In the absence of a designation or if the designee is not available, the donee or other person authorized to accept the anatomical gift may employ or authories, all of whom have signed at the direction and in the presence of the donor and of each other, and state that it has been so signed. A document of gift may designate a particular physician or surgeo least 18 years of age. An anatomical gift may be made by a document of gift signed by the donor. If the donor cannot sign, the document of gift must be signed by another individual and by two witness Instructions for preparing your Anatomical Gift Anatomical Gift Form To make an anatomical gift, limit an anatomical gift or refuse to make an anatomical gift, an individual must in most cases be atvides tools and guidelines to assist you in creating your Anatomical Gift and is designed to fulfill the obligations of the Uniform Anatomical Gift Act. Included in this kit are the following: Generalour wishes regarding the disposition of your body will be ignored. By preparing a written Anatomical Gift, you can rest assured that your desire to donate your organs will be carried out. This kit proFindLegalForms.com Information Donation Pursuant to the Uniform Anatomical Gift Act (by Living Donor) No one likes considering their own death, but by avoiding the subject, it is likely that many of y PennsylvaniaPennsylvania ________ n whose name is subscribed to this instrument appears to be of sound mind and under no duress, fraud, or undue influence. _____________________________ Notary Public My commission expires ____________ersonally and, under oath, stated that he or she is the person described in the above document and he or she signed the above document in my presence. I declare under penalty of perjury that the perso_________________________________ Notary Acknowledgment (Optional) State of ____________________ County of ____________________ On ____________________, ______________________________ came before me pignature of Donor ______________________________ Printed Name of Donor Address: ____________________________________________ City: _______________________________________________ State: ______________y written revocation of my Anatomical Gift. This statement will be delivered to all specified donees, if any, to whom a document of gift had been previously delivered. ______________________________ Sication during a terminal illness or injury addressed to a physician or surgeon; or (4) the delivery of a signed statement to a specified donee to whom a document of gift had been delivered. This is m of this state, a donor may amend or revoke an anatomical gift, not made by will, only by: (1) a signed statement; (2) an oral statement made in the presence of two individuals; (3) any form of commun__________________, I, ______________________________, the donor, fully and completely revoke the Anatomical Gift dated __________________________. Pursuant to Uniform Anatomical Gift Act and the lawsft Act, you should check the laws of your state to determine whether there are any other requirements you must meet to revoke your Anatomical Gift. Revocation of Anatomical Gift On this date ________estroy the original and all copies of your Anatomical Gift or cross out each page of the forms and mark "REVOKED" across them in bold print. Although most states have adopted the Uniform Anatomical Giorm notarized. You should also make certain that a copy of any revocation is provided to anyone who has a copy of your original Anatomical Gift, including any designated donees. You should also then dted. When you have completed the form and printed it, sign the form and make certain that you store the original where you had stored the original of your Anatomical Gift. You may choose to have the f. An anatomical gift that is not revoked by the donor before death is irrevocable and does not require the consent or concurrence of any person after the donor's death. Complete the information requesm of communication during a terminal illness or injury addressed to a physician or surgeon; or (4) the delivery of a signed statement to a specified donee to whom a document of gift had been deliveredn of Anatomical Gift form. A donor may amend or revoke an anatomical gift, not made by will, only by: (1) a signed statement; (2) an oral statement made in the presence of two individuals; (3) any foray out of the use of these materials. An attorney should be consulted for all serious legal matters. Revoking Your Anatomical Gift Instructions Following these instructions, you will find a Revocatios of use, data, or profits; or business interruption) however caused and on any theory of liability, whether in contract, strict liability, or tort (including negligence or otherwise) arising in any w the forms, be responsible or liable for any direct, indirect, incidental, special, exemplary, or consequential damages (including, but not limited to, procurement of substitute goods or services; loserials for your particular needs. The materials are used at your own risk. In no event will: i) FindLegalForms, Inc, its agents, partners, or affiliates, or ii) the providers, authors or publishers ofand Terms of Use" found at findlegalforms.com. These materials are provided "AS-IS." We do not give any express or implied warranties of merchantability, suitability or completeness for any of the matlaimer No Attorney-Client relationship is created by use of these materials. FindLegalForms, Inc. does not provide legal advice. The purchase and use of these materials is subject to the "Disclaimers esigned to fulfill the requirements of the Uniform Anatomical Gift Act. Included in this kit is the following: General Instructions for Revoking Your Anatomical Gift Revocation of Anatomical Gift Discnt to revoke the document. Until your death, it is your right to revoke your Anatomical Gift at any time. This kit provides tools and guidelines to assist you in revoking your Anatomical Gift and is dFindLegalForms.com Information Revoking an Anatomical Gift (Organ Donation Revocation) You prepared a written Anatomical Gift, but now because of a change of circumstances or a change of heart, you wa PennsylvaniaPennsylvania _____________ 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 Pennsylvania