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South Dakota _____________, __________. ______________________________ (Notary Public) My commission exp ires: __________________. 3 sses ____________________________, and _________________________ personally appeared before the undersigned officer and signed the foregoing instrument in my presence. Dated this _____________ day of ature) Print Name: ___________________________________ Address: ______________________________________ On this the __________ day of ________ 20___, the declarant, ________________________, and witne_______________________ (Witness Signature) Print Name: ___________________________________ Address: ______________________________________ _____________________________________________ (Witness Sign_________________________________ ______________________________________ Zip Code: ___________________________ The declarant voluntarily signed this document in my presence. 2 ____________________________________ __________________________________________ (Declarant's Signature) Name: ____________________________________________________________________ Address: ___________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Date: ____e). ____________________________________________________________________________ ____________________________________________________________________________ __________________________________________of the printed directives and want to write your own, or if you want to write directives in addition to the printed provisions, or if you want to express some of your other thoughts, you can do so hereatment" that may be withheld or withdrawn. _________ I do not intend to include this treatment among the "life-sustaining treatment" that may be withheld or withdrawn. (If you do not agree with any e withheld or withdrawn.") With respect to artificial nutrition and hydration, I wish to make clear that (initial only one): _________ I intend to include this treatment among the "life-sustaining tr or veins. If you do not wish to receive this form of treatment, you must initial the statement below which reads: "I intend to include this treatment, among the 'life-sustaining treatment' that may bordance with accepted medical standards as then in effect. (Artificial nutrition and hydration is food and water provided by means of a nasogastric tube or tubes inserted into the stomach, intestines,ibility of restoring consciousness to me, then provide life-sustaining treatment. 1 _________ MAXIMUM TREATMENT. Preserve my life as long as possible, but do not provide treatment that is not in accsible, then do not provide me with life-sustaining treatment, and if life-sustaining treatment is being provided to me, terminate it. If and so long as you believe that treatment has a reasonable possstoring to me the ability to think and act for myself. _________ TREAT UNLESS PERMANENTLY UNCONSCIOUS. If you believe that I am permanently unconscious and are satisfied that this condition is irreverstaining treatment is begun, terminate it. _________ TREATMENT FOR RESTORATION. Provide life-sustaining treatment only if and for so long as you believe treatment offers a reasonable possibility of rey of the following directives, space is provided below for you to write your own directives). _________ NO LIFE-SUSTAINING TREATMENT. I direct that no life-sustaining treatment be provided. If life-susions regarding my medical care. With respect to any life-sustaining treatment, I direct the following: (Initial only one of the following optional directives if you agree. If you do not agree with an CARE: I, ______________________________________ willfully and voluntarily make this declaration as a directive to be followed if I am in a terminal condition and become unable to participate in decie to use this form, please note that the form provides signature lines for you, the two witnesses whom you have selected and a notary public. TO MY FAMILY, PHYSICIANS, AND ALL THOSE CONCERNED WITH MYocument at any time by notifying your physician and other health-care providers. You should give copies of this document to your physician and your family. This form is entirely optional. If you choosstakes. This document will remain valid and in effect until and unless you revoke it. Review this document periodically to make sure it continues to reflect your wishes. You may amend or revoke this dou live or die. Prepare this document carefully. If you use this form, read it completely. You may want to seek professional help to make sure the form does what you intend and is completed without mito participate in your own medical decisions and you are in a terminal condition. This document may state what kind of treatment you want or do not want to receive. This document can control whether ys and Terms of Use found at findlegalforms.com Living Will DECLARATION This is an important legal document. This document directs the medical treatment you are to receive in the event you are unable 2 estate planning matters. 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 Disclaimerithout consulting an attorney first to make sure it fits your particular situation. Advice from a local attorney is always recommended when dealing with Living Will Information & Instructions ­ Page tended 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 starting point for you and should not be used or signed wided "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 effect or completeness. [_]These forms are not inn to the attending physician or other health-care provider. The attending physician or health-care provider shall make the revocation a part of the declarant's medical record. [_] These forms are provrd to contain revocation. A declarant may revoke a declaration at any time and in any manner without regard to the declarant's mental or physical condition. A revocation is effective upon communicatioding physician and other health-care providers shall act in accordance with the declaration or comply with the transfer requirements of § 34-12D-11. 34-12D-8. Revocation of declaration -- Medical recosician and one other physician to be in a terminal condition and no longer able to make decisions regarding administration of life-sustaining treatment. If the declaration becomes operative, the attenration may, but need not, be in the following form (see form below): 34-12D-5. When declaration becomes operative. A declaration becomes operative when the declarant is determined by the attending phytion and hydration is to be provided, withheld, or withdrawn shall be governed by the law of this state which would apply in the absence of a declaration. 34-12D-3. Declaration -- Sample form. A declato receive or not receive artificial nutrition and hydration. If the declaration does not state the declarant's preferences with respect to artificial nutrition and hydration, whether artificial nutriuals. The signing may be in the presence of a notary public who shall thereafter notarize the declaration. A declaration shall state the declarant's preferences regarding whether the declarant wishes tion governing the withholding or withdrawal of life-sustaining treatment. The declaration shall be signed by the declarant, or another at the declarant's direction, and witnessed by two adult individe, we have included useful excerpts from the South Dakota Statutes relating to Living Wills. 34-12D-2. Declaration -- Requirements as to execution. A competent adult may at any time execute a declaraction for South Dakota Living Will; (2) South Dakota Living Will. This South Dakota Living Will is based on Title 34 Chapter 12D Section 34-12D-2 et. Seq. of the South Dakota Code. For your convenienc_____________________________ _____________________________________________________________ -2- Information and Instructions South Dakota Living Will This package contains (1) Information and Instru___________________ Witness #2: Signature: ___________________________________ Date: ____________ Print Name: ______________________ Telephone Number: ____________ Residence Address: _______________________ Date: ____________ Print Name: ______________________ Telephone Number: ____________ Residence Address: _____________________________________________ __________________________________________owledged this durable power of attorney in my presence, and that he/she appears to be of sound mind and not under duress, fraud, or undue influence Witness #1: Signature: ___________________________________ (Notary Public) OR WITNESS STATEMENT I declare that the person who signed or acknowledged this Durable Power of Attorney for Health Care is personally known to me, that he/she signed or ackn__ ) ) ) -1- Subscribed, sworn to, and acknowledged before me by ________________________________, the principal, this ______ day of ____________, 20_____. (Seal) _________________________________r, of sound mind, and under no constraint or undue influence. ________________________________________ (Signature of Principal) NOTARY The State of South Dakota The County of _______________________ty that I sign it willingly (or willingly direct another to sign for me), that I execute it as my free and voluntary act for the purposes therein expressed, and that I am eighteen years of age or olde______________________________________________, the principal, sign my name to this instrument this ________ day of ____________ (month) 20 __________, and do hereby declare to the undersigned authoriey- in- fact, or if he or she is unable, unwilling or unavailable to act, by my successor attorney-in- fact, unless the attending physician determines that I have decisional capacity. I, _____________ no longer make my own medical decisions, and is not affected by physical disability or mental incompetence. The determination of whether I can make my own medical decisions is to be made by my attornuccessor agent) to make decisions for me regarding the withholding or withdrawal of artificial nutrition and hydration in all medical circumstances. This power of attorney becomes effective when I canr attorney- in-fact, and authorize him/her to make all and any health care decisions for me, including decisions to withhold or withdraw any form of life support. I expressly authorize my agent (and st) of ____________________________________________________________. (address and telephone number of successor attorney- in- fact) I have discussed my wishes with my attorney- in- fact and my successoble to act on my behalf or if I revoke that person's authority to act as my attorney- in-fact, I hereby appoint ____________________________________________________, (name of successor attorneyin- facake health care decisions on my behalf and to consent to, to reject, or to withdraw consent for medical procedures, treatment or intervention. In the event the person I appoint above refuses or is una________________________________, (name of attorney- in-fact) of _____________________________________________________ (address and telephone number of attorney- in- fact) as my attorney- in-fact to m____________________________________, (name of principal) of _____________________________________________________________ (address) an adult of sound mind, willfully and voluntarily hereby appoint __ a tax professional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com -1- Power of Attorney for Health Care I, _____________________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 withuld 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 fits 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 forms shoDakota Power of Attorney for Health Care Form. [_] 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 of Attorney for Health Care is partly based on Title 59 Section 27A16-18 et. Seq. of the South Dakota Statutes. The following are useful excerpts from the South Dakota Statutes relating to the South r Health Care This package contains (1) Information and Instruction for South Dakota Power of Attorney for Health Care; (2) South Dakota Power of Attorney for Health Care Form. This South Dakota Power 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 Information South Dakota Power of Attorney fo sure it fits your particular situation. Advice from a local attorney is always recommended when dealing with estate planning matters. Any possible tax consequences arising out of this document shouldd/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 or signed without cons ulting an attorney first to makenties 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 substitute for legal an an Advance Health Care Directive. 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 warraSouth Dakota Advance Health Care Directive This package contains both a South Dakota Power of Attorney for Health Care and a South Dakota Living Will. Together these forms are also sometimes known as South Dakota