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South Dakota e Address: _____________________________________________ _____________________________________________________________ -2- ______________________________________________ Witness #2: Signature: ___________________________________ Date: ____________ Print Name: ______________________ Telephone Number: ____________ Residenc__________________________________ Date: ____________ Print Name: ______________________ Telephone Number: ____________ Residence Address: _____________________________________________ _______________, that he/she signed or acknowledged 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 mety of _________________________ ) ) ) -1- Subscribed, sworn to, and acknowledged before me by ________________________________, the principal, this ______ day of ____________, 20_____. (Seal) ____m eighteen years of age or older, of sound mind, and under no constraint or undue influence. ________________________________________ (Signature of Principal) NOTARY The State of South Dakota The Counlare to the undersigned authority 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 aonal capacity. I, ___________________________________________________________, the principal, sign my name to this instrument this ________ day of ____________ (month) 20 __________, and do hereby deccisions is to be made by my attorney-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 decisiorney becomes effective when I can 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 dexpressly authorize my agent (and successor agent) to make decisions for me regarding the withholding or withdrawal of artificial nutrition and hydration in all medical circumstances. This power of attmy attorney-in-fact and my successor 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 e____, (name of successor attorneyin-fact) of ____________________________________________________________. (address and telephone number of successor attorney-in-fact) I have discussed my wishes with person I appoint above refuses or is unable to act on my behalf or if I revoke that person's authority to act as my attorney-in-fact, I hereby appoint ________________________________________________rney-in-fact) as my attorney-in-fact to make 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, willfully and voluntarily hereby appoint __________________________________, (name of attorney-in-fact) of _____________________________________________________ (address and telephone number of attorney for Health Care I, _________________________________________________________, (name of principal) of _____________________________________________________________ (address) an adult of sound mindout 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 -1- Power of Attoe 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 consequences arising 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 document you should havto 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 vary from time to South Dakota Statutes relating to the South Dakota 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 for Health Care Form. This South Dakota Power 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 theInformation South Dakota Power of Attorney for Health Care This package contains (1) Information and Instruction for South Dakota Power of Attorney for Health Care; (2) South Dakota Power of Attorney South Dakota