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Pennsylvania e Agent / Surrogate _______________________________ Date -5- asonable caution and prudence. I shall keep a full and accurate record of all actions, receipts and disbursements on behalf of the principal. ___________________________________ Signature of Substituter 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 shall keep the assets of the principal separate from my assets. I shall exercise retached power of attorney and am the person identified as the Substitute Agent / Surrogate for the Principal. I hereby acknowledge that in the absence of a specific provision to the contrary in the powwer of attorney unless the agent has first executed and affixed to the power of attorney an acknowledgment in substantially the following form I, ___________________________________, have read the at______ Signature of Agent / Surrogate _______________________________ Date -4- Acknowledgment by Substitute Agent (Substitute Surrogate) An agent shall have no authority to act as agent under the porom my assets. I shall exercise reasonable caution and prudence. I shall keep a full and accurate record of all actions, receipts and disbursements on behalf of the principal. ________________________ovision 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 shall keep the assets of the principal separate f___________________________, have read the attached power of attorney and am the person identified as the Agent / Surrogate for the Principal. I hereby acknowledge that in the absence of a specific prave 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 substantially the following form I, ________________ Witness's signature: ____________________________________________ Witness's address: ______________________________________________ -3- Acknowledgment by Agent (Surrogate) An agent shall hly and voluntarily signed this writing by signature or mark in my presence. Witness's signature: ____________________________________________ Witness's address: ______________________________________: ___________________________________________ Declarant's address: ____________________________________________ The declarant, or the person on behalf of and at the direction of the declarant, knowing___________________ Phone: _______________________________________________________ I made this declaration on the _________________ day of _________________. (day) (month, year) Declarant's signature Name and address of substitute surrogate (if surrogate designated above is unable to serve): Name: _______________________________________________________ Address: ___________________________________sciousness. Name: _______________________________________________________ Address: ______________________________________________________ Phone: _______________________________________________________-making: I do do not want to designate another person as my surrogate to make medical treatment decisions for me if I should be incompetent and in a terminal condition or in a state of permanent unconif I do not specifically indicate my preference regarding any of the forms of treatment listed above, I may receive that form of treatment. Other instructions (or write none): -2- Surrogate decisionon (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 kidney dialysis. I do I do do not want antibiotics. I realize that rms of treatment: I do do not want cardiac resuscitation. I do do not want mechanical respiration. do not want tube feeding or any other artificial or invasive form of I do nutrition (food) or hydratin, including any pain that might occur by withholding or withdrawing life-sustaining treatment. In addition, if I am in the condition described above, I feel especially strongly about the following foong the process of my dying, if I should be in a terminal condition or in a state of permanent unconsciousness. I direct that treatment be limited to measures to keep me comfortable and to relieve paittled commitment to refuse life-sustaining treatment under the circumstances indicated below. I direct my attending physician to withhold or withdraw life-sustaining treatment that serves only to prol_________________________________________________, being of sound mind, willfully and voluntarily make this declaration to be followed if I become incompetent. This declaration reflects my firm and seS. _________________________________ Signature of Principal / Grantor _________________________________ Name of Principal / Grantor __________________________ Date -1- Pennsylvania Declaration I, __E 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 ME THIS NOTICE AND I UNDERSTAND ITS CONTENTCAN 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 EXPLAINED MORE FULLY IN 20 PA.C.S. CH. 56. IF THERT 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 SEPARATE FROM YOUR AGEN'TS FUNDS. A COURT T 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 BECOME INCAPACITATED, UNLESS YOU EXPRESSLY LIMIHOUT 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 EXERCISED, YOUR AGENT MUST USE DUE CARE TO ACIS 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 DISPOSE OF ANY REAL OR PERSONAL PROPERTY WITwith a tax professional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com 2 Pennsylvania Declaration Notice NOTICE THE PURPOSE OF THits your particular situation. You should also consult an attorney whenever a document is negotiated with another party. Any possible tax consequences arising out of this document should be discussed should only be a starting point for you and should not be used without consulting with an attorney first. Before using or signing this document you should have an attorney review it to make sure it fpose 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 state. These formsided in section 5604 (durable powers of attorney). [_] 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 purrney to act on behalf of that principal. § 5601.1. Powers of attorney presumed durable. Unless specifically provided otherwise in the power of attorney, all powers of attorney shall be durable as provrecord of all actions, receipts and disbursements on behalf of the principal. 1 (f) Definition.--As used in this chapter, the term "agent" means a person designated by a principal in a power of atto to: · Exercise the powers for the benefit of the principal. · Keep separate the assets of the principal from those of an agent. · Exercise reasonable caution and prudence. · Keep a full and accurate 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 of attorney, the fiduciary relationship includes the duty 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 authority is proper. e) Fiduciary relationship.--An agent acting ude the following notice in capital letters at the beginning of the power of attorney. The notice shall be signed by the principal. In the absence of a signed notice, upon a challenge to the authoritym 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 principal. (c) Notice.--All powers of attorney shall inclark, 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, then it shall be witnessed by two individuals, each of whoxpressly directs to the contrary, shall be construed in accordance with the provisions of this chapter. (b) Execution.--A power of attorney shall be signed and dated by the principal by signature or melegated 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 in writing to an agent and, unless the power of attorney e CH. 56. The following are useful excerpts from the Statutes relating to the Pennsylvania Declaration Form. § 5601. General provisions. (a) General rule.--In addition to all other powers that may be dvania Declaration Form; (2) Pennsylvania Declaration Form (Power of Attorney for Health Care / Living Will) Form. This Pennsylvania Declaration Form is based on the Pennsylvania Statutes at 20 PA.C.S.e contains (1) Information and Instruction for Pennsylvania Declaration Form (Power of Attorney for Health Care / Living Will) including excerpts from the Pennsylvania Statutes relating to the PennsylPennsylvania Declaration Form Information The Pennsylvania Declaration Form is a document which contains both a Living Will and a Power of Attorney for Health Care for use in Pennsylvania. This packag Pennsylvania