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Utah tsoever. ____________________________________ Notary Public Residing at: __________________________ My commission expires: ____________________________ has read and fully understands the foregoing power of attorney, executed the same of his own volition and for the purposes set forth, and that he was acting under no constraint or undue influence wha of __________________________ ) On the ________ day of ________, ________, personally appeared before me _________________________________________________________, who duly acknowledged to me that hettending physicians and other providers of medical services as to my care and treatment. _________________________________ Signature of Principal State of ___________________________ ) ) ss. Countys power of attorney shall be and remain in effect from the time my attending physician certifies that I have incurred a physical or mental condition rendering me unable to give current directions to aarity with my desires, beliefs, and attitudes will result in directions to attending physicians and providers of medical services which would probably be the same as I would give if able to do so. Thinable to give current directions to attending physicians and other providers of medical services. I have carefully selected my above-named agent with confidence in the belief that this person's familia directive on my behalf under Section 75-2-1105, governing the care and treatment to be administered to or withheld from me at any time after I incur an injury, disease, or illness which renders me ully and voluntarily appoint ______________________________________ of ________________________________________ as my agent and attorney-in-fact, without substitution, with lawful authority to execute Health Care I, ________________________________________________________________________, of _____________________________________, this ________ day of ________, ________, being of sound mind, willfument 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- Special Power of Attorney forview 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 out of this docuate 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 have an attorney relity 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 time and from st this part unless that person has actual knowledge of the revocation. -1- [_] These forms are provided "as is" and no implied or express warranties have been made or are provided as to their suitabirecord the time, date, and place when notice of a written revocation was received. (3) There is no criminal or civil liability on the part of any person for failing to act upon a revocation made undereceipt by the attending physician and other providers of medical service of a written revocation under Subsection 75-2-1111 (b) or (c). The attending physician shall record in the declarant's medical or older who signs and dates a written instrument confirming that the expression of intent was made. (2) Any oral revocation not otherwise known to the attending physician becomes binding only upon rant or by a person signing on behalf of the declarant or acting at the direction of the declarant; (c) oral expression of an intent to revoke the directive in the presence of a witness 18 years of age being obliterated, burned, torn, or otherwise destroyed or defaced in any manner indicating an intention to effect revocation; (b) a written revocation of the directive signed and dated by the declarnt if the declarant has signed it personally, or by the person or persons who signed a directive on behalf of a declarant, based on changed circumstances or conditions or a change of mind, and by: (a)y an attorney-in-fact appointed under this section takes precedence over all previously signed directives. 75-2-1111. Revocation of directive. (1) A directive may be revoked at any time by the declaraecial power of attorney before a notary public, which shall be in substantially the following form or in a form substantially similar to the form approved by prior Utah law: (2) A directive executed blder to execute a directive under Section 75-2-1105 on behalf of the principal after the principal incurs an injury, disease, or illness which renders him unable to make a directive, by executing a spng to the Utah Power of Attorney for Health Care Form. 75-2-1106. Special power of attorney. (1) A person 18 years of age or older, the "principal," may designate any other person 18 years of age or oalth Care Form. This Utah Power of Attorney for Health Care is based on Title 75 Chapter 02 Section 75-2-1106 et. Seq. of the Utah Code. The following are useful excerpts from the Utah Statutes relatiInformation and Instructions Utah Power of Attorney for Health Care This package contains (1) Information and Instruction for Utah Power of Attorney for Health Care ; (2) Utah Power of Attorney for He Utah