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Pennsylvania 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 Pennsylvania