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Pennsylvania _____________________________________ 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 Pennsylvania