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Vermont amped -5- ____________________________ as identification. _________________________________ Signature of person taking acknowledgment (Notary Public) _________________________________ Name typed, printed, or stforegoing instrument was acknowledged before me this _____ day of ____________________, ______ by __________________________ (name of Principal), who is personally known to me or who has produced ___________________________________ City: __________________________________ State: ___________________________________ State of __________________________ ) ) ss County of ________________________ ) The ________ Name: ___________________________________ City: __________________________________ State: ___________________________________ Witness Signature: ___________________________________ Name: ____n ________________ (date), at _______________________ (city), __________________________ (state). ________________________________ Signature of Principal Witness Signature: ___________________________t in good faith and/or willful misconduct, while acting under the authority of this Power of Attorney. I may revoke this Power of Attorney at any time by providing written notice to my Agent. Signed oination, shall be held harmless. -4- Agent shall not be liable for losses resulting from judgment errors made in good faith. However, Agent will be liable for breach of fiduciary duty, failure to acreliance on this power of attorney. If this Durable Power of Attorney is terminated by operation of law, any person relying in good faith on the authority of this document, without notice of such termey is not effective as to a third party until the third party has actual knowledge of the revocation. I agree to indemnify the third party for any claims that arise against the third party because of of my Agent; and/or (c) my assets to be subject to a general power of appointment by my Agent. Any third party who receives a copy of this document may act under it. Revocation of the power of attorny are limited to the extent necessary to prevent (a) my income to be taxable to my Agent; (b) my Agent to have any rights or ownership with respect to any life insurance policies I may own on the lifeo the reasons for the use or issuance of this power-ofattorney or as to the disposition of any proceeds paid to my Agent based on this document. The powers granted to my Agent by this power-of-attorneble under applicable law, then the remaining unaffected parts of the document shall still remain in full force and effect and not be affected by any partial invalidity. No person needs to inquire as t, rights, acts or powers are not intended to restrict or limit the definition or scope of powers granted herein in any manner. If any part of this document is held to be invalid, illegal or unenforceashall provide an accounting for all funds handled and all acts performed as my Agent. This Power of Attorney shall be construed as broadly as a General Power of Attorney. The listing of specific terms shall also be entitled to reasonable compensation for any services provided as my Agent If so requested by myself or any authorized personal representative or fiduciary acting on my behalf, my Agent by a licensed medical doctor. My Agent shall be entitled to reimbursement of all reasonable expenses incurred as a result of carrying out any provision of this Power of Attorney. If desired, my Agentcapacity" shall mean a lack of capacity to receive and evaluate information effectively, to communicate decisions, and/or to manage my financial resources and affairs properly, as certified in writingeath. This Power of Attorney shall not terminate on my subsequent disability, incapacity or lack of mental competence, except as provided by any applicable statute. As used herein, "disability" or "insubsequent disability or incapacity as certified in writing by a licensed medical doctor. The rights, powers, and authority of this document shall remain in full force and effect thereafter until my d the result is that the disclaimed assets pass directly or indirectly to my Agent or my Agent's estate. This Durable Power of Attorney and all rights and powers therein shall become effective upon my h might be transferred or distributed to me from any other person, estate, trust, or other entity, as may be appropriate. However, Agent may not disclaim assets, to -3- which I would be entitled, ify of my assets to the trustee of any revocable trust created by me, if such trust exists at the time of such transfer. 17. To disclaim any interest (subject to other provisions of this document), whicsets to discharge any of my Agent's legal obligations, including any obligations of support which my Agent may owe to others, excluding those whom I am legally obligated to support. 16. To transfer anrs of my Agent's estate, (b) exercise any powers of appointment I may hold in favor of my Agent, my Agent's estate, my Agent's creditors, or the creditors of my Agent's estate, or (c) use any of my as authorized by this document, (a) gift, appoint, assign or designate any of my assets, interests or rights, directly or indirectly, to my Agent, my Agent's estate, my Agent's creditors, or the creditoift tax annual exclusion amount in any one calendar year, and this annual right shall be non-cumulative and shall lapse at the end of each calendar year. However, my Agent may not, unless specificallyorm Gifts to Minors Act or the Uniform Transfers To Minors Act. Any gifts made shall be limited to gifts that qualify for the federal gift tax annual exclusion, shall not exceed in value the federal gd if necessary, to file any state and federal gift tax returns and documents. Gifts to minors may be made to the minor directly or parent, guardian or close friend of the minor or pursuant to the Unif charitable contributions of my real, personal, tangible or intangible property, to such persons or organizations without regard to whether such gifts are a part of my estate planning or otherwise, anobtain or provide information to and from any agency, including governmental agencies, relating to tax matters and to negotiate, compromise or settle any matter with such agency. 15. To make gifts andny documents with any federal, state, local or other governmental body, including, but not limited to, federal, state, local or other income and tax returns and necessary and/or related documents; to ance as may be appropriate, including but not limited to, attorneys, accountants, investment professionals, brokers and real estate agents. 14. To prepare, or cause to be prepared, sign, and/or file astments. 12. To maintain and/or operate any business that I currently own or have an interest in or may own or have an interest in, in the future. 13. To employ any professional and/or business assistxamine, remove, keep or otherwise dispose of the contents. 11. To exercise any and all rights, including proxy rights, with respect to stocks, bonds, debentures, commodities, options or any other inveurities. -2- 10. To have access to any safe deposit box, vault or other storage area owned or leased by me alone or in conjunction with any other person, including access to their contents, and to en, firm, corporation or political entity; to perform any act necessary to deposit, negotiate, sell or transfer any note, security, or draft of the United States of America, including U.S. Treasury Secegotiating or endorsing any checks or other instruments, obtaining bank statements, passbooks, drafts, warrants, money orders, certificates, cashier checks, cash or vouchers payable to me by any personts with financial institutions; to conduct any business with any banking or financial institution with respect to any of my accounts, including, but not limited to, making deposits and withdrawals, ne bank accounts, including, but not limited to, checking accounts, savings accounts, certificates of deposit, investment accounts, brokerage accounts, retirement plan accounts, and other similar accoury and social security benefits), and to appoint anyone, including my Agent, to act as my "Representative Payee" for the purpose of receiving Social Security benefits. 9. To open, maintain and/or closre applications, provide information, and perform any other reasonable request by any government or its agencies in connection with governmental benefits (including but not limited to, medical, militaall payments I receive from any annuity, pension, retirement benefits, retirement plans, insurance benefits and government program including, but not limited to, Social Security and Medicare; to prepainsurance upon my life or the life of any other appropriate person and to make any elections and disclaimers under such policies. 8. To receive, deposit, hold, demand, deal with and/or sue to recover all monies which may become due and owing to me by reason of such transaction. 7. To apply for, purchase, maintain and/or deal with insurance and annuity contracts, insurance policies, including life sell or encumber any homestead that I now own or may own in the future; the right to remove tenants and to recover possession; and the right to ask for, demand, sue for, collect, recover and receive erty or asset whatsoever, tangible or intangible (now owned or acquired in the future by me) and to execute any necessary document, instrument or deed for such transactions. This includes the right toortgage, improve, repair, exchange, invest, reinvest and in any other manner (on such terms and at prices my Agent may deem proper) deal with all, any part or any interest in any real or personal prop or due in the future, owned by, due, owing payable, or belonging to, me or in which I have or may hereafter acquire any interest, to have, or use. 6. To maintain, manage, insure, lease, rent, sell, mhecks, drafts, causes of action, bequests, deposits, notes, interests, dividends, certificates of deposit, any and all documents of title and demands whatsoever, whether agreed to or disputed, now due claim, against me or asserted on my behalf against any other person or entity. -1- 5. To receive, hold, possess and/or invest any and all sums of money, accounts, debts, bonds, commercial papers, cever kind and nature as may be. 3. To request, ask, demand, sue and take any and all legal steps necessary to recover and collect any amount or debt owed to me. 4. To adjust, compromise and settle anytutions, proofs of loss, evidences of debts, releases, and satisfaction of mortgages, lien, judgments, security agreements and other debts and obligations and such other instruments in writing of whats, proxies, warrants, commercial papers, withdrawal and deposit slips, certificates of deposit of, or investments with or through banks, savings and loan, brokers, mutual fund companies or other insti covenants, conveyances, deeds, options, trust deeds, security agreements, leases, mortgages, notes, insurance policies, receipts, title documents, checks, drafts, letters of credit, stock certificatexecute any written agreement and document necessary to enter into any such contract and/or agreement, including but not limited to applications, assignments, bills of sale or lading, bonds, contracts,: 1. To conduct, engage in, and transact any and all lawful business of whatever kind or nature, on my behalf and in my name. 2. To enter into binding contracts on my behalf and to sign, endorse and esubstitute or substitutes, shall lawfully do or cause to be done by virtue of this power of attorney and the rights hereby granted. My Agent's powers and authority shall include, but not be limited toction, thing, business, property, real or personal, tangible or intangible, or matter whatsoever as I could do if personally present. I hereby ratify and confirm all acts that my Agent, or my Agent's hall have full power and authority to perform any act, power, duty, legal right or obligation whatsoever that I now have or may later acquire in connection with or relating to any person, item, transa___ maintaining an address at: _____________________________________________________ as my alternate or successor Agent, as necessary, to serve with the same powers, rights and discretions. My Agent s__________________ my true and lawful attorney-in-fact for me and in my name, and in my behalf. If the above named Agent is unable to serve for any reason, I appoint __________________________________ address at _______________________________________________ do hereby make and appoint ________________________________________ ("Agent") maintaining an address at: ___________________________________r legal responsibilities of an agent. -3- DURABLE POWER OF ATTORNEY Effective upon Disability KNOW ALL PERSONS BY THESE PRESENTS: I, ____________________________________ ("Principal") maintaining anand other health-care decisions for you. You may revoke this power of attorney if you later wish to do so. AGENT: By accepting or acting under the appointment, the agent assumes the fiduciary and othee of this power of attorney document, is legally binding upon you. If you have any questions about these powers, obtain competent legal advice. This document does not authorize anyone to make medical agent") with the power to handle business and legal matters on your behalf, including the power to sell, mortgage or dispose of your property. Any such action undertaken by your agent, within the scopION! PRINCIPAL: The Powers granted by this power of attorney document are broad and sweeping. Before signing this document, consider its consequences. You ("principal") are providing another person ("n is general information that is not state specific. Whenever appropriate, the instructions included with the forms packages offered for sale, generally include state specific instructions. -2- CAUTesses are necessary, if the Agent will deal with any real estate in Florida. Please note that this information is not intended as and is not a substitute for legal advice. Furthermore, this informatioe Power of Attorney to be recorded as a public record, if necessary. Although, some states don't require that a Durable Power of Attorney be witnessed, it is always a very good idea to do so. Two witnspecially if the Agent will be dealing with any real property. Notarization will make it more difficult for any third party to challenge the validity of the Power of Attorney and will allow the Durablorney is signed, in the event the original Agent is unable to serve or continue to serve as the Agent. A Durable Power of Attorney should always be notarized, even if your state does not require it, eof Attorney at any time. Since this Durable Power of Attorney takes effect only after the Principal becomes disabled or incompetent, an alternate Agent can be designated, at the time this Power of Attn the Principal. This is especially important if the Principal is incapacitated when the Power of Attorney goes into effect, or the Agent undertakes the acts. The Principal can revoke a Durable Power ney. A Power of Attorney is a "powerful" instrument and should be granted with care. Any action undertaken by the Agent, within the scope of the Power of Attorney document, will be legally binding uponey" is not used here to mean "lawyer". The person acting as the attorney-in-fact for the Principal does not need to be a lawyer. Almost anyone can be appointed an attorney-in-fact by a power of attort") to act on his or her behalf, even if the Principal later becomes incapacitated. This particular Form becomes effective upon the disability or incapacity of the Principal. Note that the word "attorctive upon Disability A Durable Power of Attorney allows a natural "mentally competent " person (called the "Principal" or "Principal") to authorize someone else (called the "Agent" or "AttorneyIn-Facting a document with another party. [_] The purchase and use of these forms, is subject to the Disclaimers and Terms of Use found at findlegalforms.com -1- Information Durable Power of Attorney Effe not a substitute for legal advice. These forms should only be a starting point for you and should not be used without consulting with an attorney first. An Attorney should be consulted before negotiahoice as Agent is unable to serve or continue to serve as the Agent. This section can be removed, deleted (and initialed) or the words "no one" can be entered. [_] These forms are not intended and are sweeping, as the Agent has the power to handle business and legal matters on the Principal's behalf. [_] This document offers the option of nominating an alternate Agent in the event that the first cthe Agent (or attorney-in-fact) as to the tasks the Agent should complete. The Grantor should also be very careful in the selection of the Agent. The powers granted by this document are very broad and a witness. [_] The Principal should keep the original document, as well as a copy. The Agent should have access to the original document as needed. [_] The Principal should be careful in instructing ecord, if necessary. [_] Two witnesses need to sign the Power of Attorney. The witnesses should be competent adults. Anyone related by blood or marriage to the Principal, Agent or Notary should not beincipal. [_] The Principal (i.e. the person granting the Power of Attorney) should sign the document before a Notary. Notarization will allow the Durable Power of Attorney to be recorded as a public rtion for Durable Power of Attorney Effective upon Disability; (3) Durable Power of Attorney Effective upon Disability [_] This Durable Power of Attorney becomes effective upon the Disability of the PrInstructions & Checklist Durable Power of Attorney Effective upon Disability [_] This package contains (1) Instructions & Checklist for Durable Power of Attorney Effective upon Disability; (2) Informa VermontVermont of which the person(s) acted, executed the instrument. WITNESS my hand and official seal. Signature __________________________________ (Seal) t and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf________________________________ ___________, personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrumen__________ before me, (here insert name and title of the officer), personally appeared ________________________________________________________________________ ________________________________________________ Names of institutions/individuals who have been provided a copy of this revocation: Notary Acknowledgment State of __________________________ County of ________________________ ) ) ss ) On ______ State:_________________________ Witness Signature:__________________ Date: ___________________________ Name: ___________________________ City: _________________________ State:_________________ ___________________ (date). _____________________________ Principal Witness Signature:__________________ Date: ___________________________ Name: ___________________________ City: ___________________ artificial life sustaining procedures is revoked and withdrawn and this document provides notice of such revocation. IN WITNESS WHEREOF, I have signed this Health Care Power of Attorney Revocation on______________________________ (title of document(s)) dated __________________ and all power and authority granted thereby including powers for making health care decisions on my behalf and concerningRevocation I, ___________________________________ (Principal) maintaining an address at __________________________________________________ (address of Principal), hereby revoke my ____________________ion that is not state specific. Whenever appropriate, the instructions included with the forms packages offered for sale, generally include state specific instructions. Health Care Power of Attorney revoked. This revocation becomes effective immediately. Please note that this information is not intended as and is not a substitute for legal advice. Furthermore, this information is general informate Power of Attorney Revocation is used by the Grantor to give notice that a previously granted Health Care Power of Attorney (sometimes referred to as a Living Will or Health Care Directive) has been alth Care Power of Attorney Revocation If the Grantor of a Health Care Power of Attorney decides to revoke the document, it is almost always required that the revocation be in writing. The Health Carfor you and should not be used without consulting with an attorney first. The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Information Hetify both. These forms are not intended and are not a substitute for legal advice. Laws are different from state to state and may change from time to time. These forms should only be a starting point e revocation document. If more than one document is being revoked, then each document needs to be identified i.e. if you are revoking a Health Care Power of Attorney and a Living Will, be sure to idenpies of the Health Care Power of Attorney so as to avoid any questions about the revocation or its effectiveness. The exact full title of the document(s) that you are revoking should be inserted in thon. In the event the original power of attorney was filed publicly (i.e. recorded), then the notice of revocation should also be filed publicly, in the same manner. The Principal should destroy any coceived a copy of the original Power of Attorney or who may have dealt with the Agent acting on behalf of the Principal. It is a good idea to keep a record of anyone who was sent a copy of the revocatio the Principal, the Agent or the Notary should not be a witness. The Principal should keep a copy of the revocation in his/her files. Copies of the revocation should be sent to anyone who may have reough not always required, it is always a good idea to also have two witnesses sign the Revocation of Power of Attorney. The witnesses should be adults. Generally, anyone related by blood or marriage tified mail receipt, delivery receipt etc..). Any health care providers need to be given a copy of the Revocation as well and copies of the revocation should be kept in any relevant medical files. Alth show that it was the Grantor's intent to revoke the Power of Attorney. If possible, the Principal should keep a copy of any document showing that the Agent received the original revocation (i.e. certd. Notarization is also necessary to record the revocation. This revocation becomes effective immediately. The original or a copy of the revocation must be given to the Agent (i.e. Attorney-inFact) tohe Health Care Power of Attorney Revocation before a Notary even if it is not required. Notarization will also help to ensure that the revocation is effective and support its authenticity if challengeer of Attorney Revocation (3) Health Care Power of Attorney Revocation The Principal (i.e. the person granting the Health Care Power of Attorney Revocation; sometimes called the Grantor) should sign tInstructions & Checklist Health Care Power of Attorney Revocation This package includes (1) Checklist & Instructions for Health Care Power of Attorney Revocation (2) Information about Health Care Pow VermontVermont ______________________ Date: _________________________________________ Address: ______________________________________ Print Name: ____________________________________ 3 care home): I declare that I have personally explained the nature and effect of this durable power of attorney to the principal and that the principal understands the same. Signature: __________________________________ Statement of ombudsman, hospital representative or other authorized person (to be signed only if the principal is in or is being admitted to a hospital, nursing home or residential_____ 2 Address: ______________________________________ _____________________________________________ (Witness Signature) Print Name: ___________________________________ Address: ___________________ he or she is aware of the nature of the document and is signing it freely and voluntarily. _____________________________________________ (Witness Signature) Print Name: _________________________________ Signature I declare that the principal appears to be of sound mind and free from duress at the time the durable power of attorney for health care is signed and that the principal has affirmed that___________________________________________________ In witness whereof, I have hereunto signed my name this ________. day of ______________, 20 ____ . ________________________________________________stitutions will have signed copies: _______________________________________________________________________ _______________________________________________________________________ ____________________nt. I have read and understand the information contained in the disclosure statement. The original of this document will be kept at ___________________________________ and the following persons and in____________________________________ (address and telephone numbers) as alternate agent. I hereby acknowledge that I have been provided with a disclosure statement explaining the effect of this documeevent the person I appoint above is unable, unwilling or unavailable to act as my health care agent, I hereby appoint __________________________________________. (name of Agent) of ___________________ecline all other treatment the primary purpose of which is to prolong my life. I want my life sustained by any reasonable medical measures, regardless of my condition. ____________ (initial) In the le prospect of regaining the ability to think and act for myself, I want care directed to my comfort and dignity and also want artificial nutrition and hydration if needed, but authorize my agent to dine all treatment (including artificial nutrition and hydration) the primary purpose of which is to prolong my life. 1 ____________ (initial) If I suffer a condition from which there is no reasonabI suffer a condition from which there is no reasonable prospect of regaining my ability to think and act for myself, I want only care directed to my comfort and dignity, and authorize my agent to decl AGREE WITH ONE OF THESE STATEMENTS, YOU MAY IINITIAL THE STATEMENT APPROPRIATE STATEMENT IN THE SPACE PROVIDED (you should delete or cross-out the inapplicable statements): ____________ (initial) If T IS OF PARTICULAR IMPORTANCE. For your convenience in dealing with that subject, some general statements concerning the withholding or removal of life-sustaining treatment are set forth below. IF YOU____________________________________________ _______________________________________________________________________ (attach additional pages as necessary) (b) THE SUBJECT OF LIFE-SUSTAINING TREATMENto you for any other reason. _______________________________________________________________________ _______________________________________________________________________ ___________________________ions whether to continue or discontinue artificial nutrition and hydration; or instructions to refuse any specific types of treatment that are inconsistent with your religious beliefs or unacceptable AND LIMITATIONS REGARDING HEALTH CARE DECISIONS. Here you may include any specific desires or limitations you deem appropriate, such as when or what life-sustaining measures should be withheld; directise in this document. This durable power of attorney for health care shall take effect in the event I become unable to make my own health care decisions. (a) STATEMENT OF DESIRES, SPECIAL PROVISIONS, ___________________. (name of Agent) of _______________________________ (address and telephone numbers)as my agent to make any and all health care decisions for me, except to the extent I state otherwho have a claim against you. 2 Durable Power Of Attorney For Health Care I , ________________________________________________________ (name of Principal) hereby appoint _____________________________ have designated as your agent; your health or residential care provider or one of their employees; your spouse; your lawful heirs or beneficiaries named in your will or a deed; creditors or persons wED IN THE PRESENCE OF TWO (2) OR MORE QUALIFIED WITNESSES WHO MUST BOTH BE PRESENT WHEN YOU SIGN OR ACKNOWLEDGE YOUR SIGNATURE. THE FOLLOWING PERSONS MAY NOT ACT AS WITNESSES: · · · · · the person youble or ineligible to act as your agent. Any alternate agent you designate will have the same authority to make health care decisions for you. THIS POWER OF ATTORNEY WILL NOT BE VALID UNLESS IT IS SIGNy not be changed or modified. If you want to make changes in the document you must make an entirely new one. You may wish to designate an alternate agent in the event that your agent is unwilling, unaiven to you or stopped over your objection. You have the right to revoke the authority granted to your agent by informing him or her or your health care provider orally or in writing. This document mas made in good faith on your behalf. Even after you have signed this document, you have the right to make health care decisions for yourself as long as you are able to do so, and treatment cannot be gour physician and give each a signed copy. You should indicate on the document itself the people and 1 institutions who will have signed copies. Your agent will not be liable for health care decision not permit a person to do both at the same time. You should inform the person you appoint that you want him or her to be your health care agent. You should discuss this document with your agent and yncy, hospital, nursing home, or residential care home, other than a relative), that person will have to choose between acting as your agent or as your health or residential care provider; the law doespoint as agent should be someone you know and trust and must be at least 18 years old. If you appoint your health or residential care provider (e.g. your physician, or an employee of a home health age. You do not need a lawyer's assistance to complete this document, but if there is anything in this document that you do not understand, you should ask a lawyer to explain it to you. The person you ap nature and range of decisions which may be made on your behalf. If you do not have a physician, you should talk with someone else who is knowledgeable about these issues and can answer your questions about your health care as you would have had. It is important that you discuss this document with your physician or other health care providers before you sign it to make sure that you understand theete your statement. Your agent will be obligated to follow your instructions when making decisions on your behalf. Unless you state otherwise, your agent will have the same authority to make decisionssure you receive. Your agent's authority will begin when your doctor certifies that you lack the capacity to make health care decisions. You may attach additional pages if you need more space to complsent to medical treatment and may make decisions about withdrawing or withholding life-sustaining treatment. You may state in this document any treatment you do not desire or treatment you want to be e or treat your physical or mental condition. Your agent therefore can have the power to make a broad range of health care decisions for you. Your agent may consent, refuse to consent, or withdraw conent the authority to make any and all health care decisions for you when you are no longer capable of making them yourself. "Health care" means any treatment, service or procedure to maintain, diagnosE THIS IS AN IMPORTANT LEGAL DOCUMENT. BEFORE SIGNING THIS DOCUMENT, YOU SHOULD KNOW THESE IMPORTANT FACTS: Except to the extent you state otherwise, this document gives the person you name as your agrms is subject to the Disclaimers and Terms of Use found at findlegalforms.com 3 Vermont Durable Power Of Attorney for Health Care INFORMATION CONCERNING THE DURABLE POWER OF ATTORNEY FOR HEALTH CARways recommended when dealing with 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 foe forms should only be a starting point for you and should not be used or signed without consulting an attorney first to make sure it fits your particular situation. Advice from a local attorney is alfic 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 state to state. Thesf responsible for the principal's care of the revocation. [_] These forms are provided "as is" and no implied or express warranties have been made or are provided as to their suitability for any speciovided with a revocation of a durable power of attorney for health care shall immediately record the revocation in the principal's medical record and notify the agent, the attending physician and staff attorney for health care; or (3) by the divorce of the principal and spouse, where the spouse is the principal's agent. (b) A principal's health or residential care provider who is informed of or pr or a health or residential care provider orally, or in writing, or by any other act evidencing a specific intent to revoke the power; (2) by execution by the principal of a subsequent durable power oresence and at the principal's express direction. 14 V.S.A. § 3457. (Revocation) (a) A durable power of attorney for health care shall be revoked: 2 (1) by notification by the principal to the agently and voluntarily. If the principal is physically unable to sign, the durable power of attorney for health care may be signed by the principal's name written by some other person in the principal's pind and free from duress at the time the durable power of attorney for health care was signed and that the principal affirmed that he or she was aware of the nature of the documents and signed it freece or by operation of law or any other person who has, at the time of execution, any claims against the estate of the principal. The witnesses shall affirm that the principal appeared to be of sound movider's employee, the principal's spouse, heir, or reciprocal beneficiary, a person entitled to any part of the estate of the principal upon the death of the principal under a will or deed in existenhe principal in the presence of at least two or more subscribing witnesses, neither of whom shall, at the time of execution, be the agent, the principal's health or residential care provider or the prelative of the principal who is an employee of the principal's residential care provider. 14 V.S.A. § 3456. (Execution and witnesses) The durable power of attorney for health care shall be signed by ts: (1) the principal's health care provider; (2) a nonrelative of the principal who is an employee of the principal's health care provider; (3) the principal's residential care provider; or (4) a nonrt term is defined in section 2002 of Title 18. 14 V.S.A. § 3455. (Restrictions on who can act as agent) A person may not exercise the authority of agent while serving in one of the following capacitieare. (9) "Residential care provider" means an individual or facility licensed, certified or otherwise authorized or permitted by law to operate, for profit or otherwise, a residential care home as thader the program established within the office on aging pursuant to the Older Americans Act of 1965, as amended. (8) "Principal" means an adult who has executed a durable power of attorney for health ced by law to administer health care, for profit or otherwise, in the ordinary course of business or professional practice. 1 (7) "Ombudsman" means a person appointed as a long-term care ombudsman unprocedure to maintain, diagnose or treat an individual's physical or mental condition. (6) "Health care provider" means an individual or facility licensed, certified or otherwise authorized or permittth care decisions executed in accordance with the provisions of this chapter. (5) "Health care decision" means consent, refusal to consent, or withdrawal of consent to any care, treatment, service or ficant benefits and harms of and reasonable alternatives to any proposed health care. (4) "Durable power of attorney for health care" means a document delegating to an agent the authority to make healreatment and care of the patient. (3) "Capacity to make health care decisions" means the ability to understand and appreciate the nature and consequences of a health care decision, including the signi decisions is delegated under a durable power of attorney for health care. (2) "Attending physician" means the physician, selected by or assigned to a patient, who has primary responsibility for the tor designation of an individual to make health care decisions on their behalf. 14 V.S.A. § 3452. (Definitions) As used in this chapter: (1) "Agent" means an adult to whom authority to make health careor Health Care Form. 14 V.S.A. § 3451. (Statement of purpose) The purpose of this chapter is to enable adults to retain control over their own medical care during periods of incapacity through the priHealth Care is based on Vermont Statutes Title 14 Chapter 121 Section 3466. For your convenience, we have included useful excerpts from the Vermont Statutes relating to the Durable Power Of Attorney Fcerpts from the Vermont Statutes relating to the Durable Power Of Attorney For Health Care Form; (2) Vermont Durable Power Of Attorney For Health Care Form. This Vermont Durable Power Of Attorney For Information and Instructions Vermont Durable Power Of Attorney For Health Care This package contains (1) Information and Instruction for Vermont Durable Power Of Attorney For Health Care, including ex VermontVermont _______________________________ _______________________________________________________ 18 V.S.A. § 5253. ___________ Witness:________________________________________________________ Copies of this request have been given to: _______________________________________________________ _________________________________________ Signed: ________________________________________________________ Date:__________________________________________________________ Witness:________________________________________________________________________________________________ __________________________________________________________________________________ _________________________________________________________________ enforceable, I hope that those to whom this will is addressed will regard themselves as morally bound by these provisions. Other directions (optional ­ or write none): _______________________________l consideration and is in accordance with my strong convictions and beliefs. I want the wishes and directions here expressed carried out to the extent permitted by law. Insofar as they are not legallyy extraordinary measures. I do, however, ask that medication be mercifully administered to me to alleviate suffering even though this may shorten my remaining life. This statement is made after carefuhe situation should arise in which I am in a terminal state and there is no reasonable expectation of my recovery, I direct that I be allowed to die a natural death and that my life not be prolonged b when I, _________________________________________ , can no longer take part in decisions of my own future, let this statement stand as an expression of my wishes, while I am still of sound mind. If tbe. To any individual who may become responsible for my health, welfare or affairs. Death is as much a reality as birth, growth, maturity and old age-it is the one certainty of life. If the time comese Disclaimers and Terms of Use found at findlegalforms.com Terminal Care Document (Living Will) To my family, my physician, my lawyer, my clergyman. To any medical facility in whose care I happen to n dealing with 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 thbe a starting point for you and should not be used or signed without consulting an attorney first to make sure it fits your particular situation. Advice from a local attorney is always recommended whe 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 should only ld only postpone the moment of death. [_] 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 or as tonjury, disease or illness which regardless of the application of life-saving procedures would, within reasonable medical judgment, produce death and where application of life-sustaining procedures wou actively participate in the decision-making process. (4) "Physician" means a medical doctor licensed to practice in the state of Vermont. (5) "Terminal state" means an incurable condition caused by iecuted, contains the express direction that no extraordinary measures be taken when the person executing said document is in a terminal state, without hope of recovery from such state and is unable too artificially postpone the moment of death and where, in the judgment of the attending physician, the patient is in a terminal state. (3) "Terminal care document" means a document which, when duly exwhich utilizes mechanical or other artificial means to sustain, restore, or supplant a vital function which, in the judgment of the attending physician, when applied to the patient, would serve only te physician selected by, or assigned to the patient, who has primary responsibility for the treatment and care of the patient. (2) "Extraordinary measures" means any medical procedure or intervention e document may be revoked only as provided herein. 18 V.S.A. § 5252. (Definitions) The following definitions shall be applicable in the construction of this chapter: (1) "Attending physician" means th or 2, or by burning, tearing or obliterating the same or by causing the same to be done by some other person Information & Instructions ­ Page 2 at his direction and in his presence. A terminal carons of sections 5253 and 5254 of this title may revoke the same orally in the presence of two or more witnesses, at least one of whom shall not be a spouse or a relative as specified in 15 V.S.A. §§ 1erson who has at the time of the witnessing thereof any claims against the estate of the person. 18 V.S.A. § 5257. (Revocation) A person who has validly executed a document consistent with the provisiribing witnesses, none of whom shall be the person's spouse, heir, reciprocal beneficiary, attending physician or person acting under the direction or control of the attending physician or any other pns about his care. 18 V.S.A. § 5254. (Execution and witnesses) The document set forth in section 5253 of this title shall be executed by the person making the same in the presence of two or more subscng that no extraordinary measures be used to prolong his life when he is in a terminal state. The document shall only be effective in the event that the person is incapable of participating in decisiod or withdrawn. 18 V.S.A. § 5253. (Terminal care document) A person of sound mind who is 18 years of age or older may execute at any time a document commonly known as a terminal care document, directiinued with dignity and without pain. A person has a fundamental right to determine whether or not life-sustaining procedures which would cause prolongation of life beyond natural limits, should be usemedical treatment he will receive in the event that his physical state reaches such a point of deterioration that he is in a terminal state and there is no reasonable expectation that life can be contermont Statutes relating to Living Wills. 18 V.S.A. § 5251. (Purpose and policy) The state of Vermont recognizes that a person as a matter of right may rationally make an election as to the extent of minal Care Document (Living Will). This Vermont Terminal Care Document is based on Vermont Statutes Title 18 Chapter 111 Section 5253. For your convenience, we have included useful excerpts from the VInformation and Instructions Vermont Terminal Care Document (Living Will) This package contains (1) Information and Instruction for Vermont Terminal Care Document (a.k.a. Living Will); (2) Vermont Ter VermontVermont _________________ Name: _______________________________________________ Address: ____________________________________________ City: _______________________________________________ State: ______________________________: _______________________________________________ State: _______________________________________________ SECOND WITNESS: Date: __________________ Signature: ___________________________________________ITNESS: Date: __________________ Signature: ___________________________________________ Name: _______________________________________________ Address: ____________________________________________ Cityion and in the presence of the Donor and each other. The individual signing the Donation of Gift was directed to do so by the Donor and signed the document in his/her presence as well as ours. FIRST Wnd by two witnesses, all of whom have signed at the direction and in the presence of the donor and of each other, and state that it has been so signed.] Witness Statement: We have signed at the direct____________________ WITNESS FORM [An anatomical gift may be made only by a document of gift signed by the donor. If the donor cannot sign, the document of gift must be signed by another individual a_ Print your name: ______________________________________ Address: ____________________________________________ City: _______________________________________________ State: ___________________________n, surgeon, technician, or enucleator to carry out the appropriate procedures. SIGNATURE: (Sign and date the form here:) Date: __________________ Sign your name: _____________________________________the appropriate procedures. In the absence of a designation or if the designee is not available, the donee or other person authorized to accept the anatomical gift may employ or authorize any physiciaof the following you do not want): (1) Transplant (2) Therapy (3) Research (4) Education (Optional) I designate ___________________________________ as my particular physician or surgeon to carry out __ ________________________________________________________________________ ________________________________________________________________________ My gift is for the following purposes (strike any x): Give any needed organs, tissues, or parts, OR Give the following organs, tissues, or parts only: ____________________________ ______________________________________________________________________ for all serious legal matters. Anatomical Gift by Living Donor Pursuant to Uniform Anatomical Gift Act Upon my death, I ____________________________________ (the "Donor"), hereby (mark applicable boand on any theory of liability, whether in contract, strict liability, or tort (including negligence or otherwise) arising in any way out of the use of these materials. An attorney should be consultedntal, special, exemplary, or consequential damages (including, but not limited to, procurement of substitute goods or services; loss of use, data, or profits; or business interruption) however caused risk. In no event will: i) FindLegalForms, Inc, its agents, partners, or affiliates, or ii) the providers, authors or publishers of the forms, be responsible or liable for any direct, indirect, incideovided "AS-IS." We do not give any express or implied warranties of merchantability, suitability or completeness for any of the materials for your particular needs. The materials are used at your own erials. FindLegalForms, Inc. does not provide legal advice. The purchase and use of these materials is subject to the "Disclaimers and Terms of Use" found at findlegalforms.com. These materials are pran anatomical gift. During a terminal illness or injury, the refusal may be an oral statement or other form of communication. Disclaimer No Attorney-Client relationship is created by use of these matocument of gift, (ii) a statement attached to or imprinted on a donor's motor vehicle operator's or chauffeur's license, or (iii) any other writing used to identify the individual as refusing to make the consent or concurrence of any person after the donor's death. An individual may refuse to make an anatomical gift of the individual's body or part by (i) a writing signed in the same manner as a ddelivery of a signed statement to a specified donee to whom a document of gift had been delivered. An anatomical gift that is not revoked by the donor before death is irrevocable and does not require ) a signed statement; (2) an oral statement made in the presence of two individuals; (3) any form of communication during a terminal illness or injury addressed to a physician or surgeon; or (4) the f, after death, the will is declared invalid for testamentary purposes, the validity of the anatomical gift is unaffected. A donor may amend or revoke an anatomical gift, not made by will, only by: (1ze any physician, surgeon, technician, or enucleator to carry out the appropriate procedures. An anatomical gift by will takes effect upon death of the testator, whether or not the will is probated. In to carry out the appropriate procedures. In the absence of a designation or if the designee is not available, the donee or other person authorized to accept the anatomical gift may employ or authories, all of whom have signed at the direction and in the presence of the donor and of each other, and state that it has been so signed. A document of gift may designate a particular physician or surgeo least 18 years of age. An anatomical gift may be made by a document of gift signed by the donor. If the donor cannot sign, the document of gift must be signed by another individual and by two witness Instructions for preparing your Anatomical Gift Anatomical Gift Form To make an anatomical gift, limit an anatomical gift or refuse to make an anatomical gift, an individual must in most cases be atvides tools and guidelines to assist you in creating your Anatomical Gift and is designed to fulfill the obligations of the Uniform Anatomical Gift Act. Included in this kit are the following: Generalour wishes regarding the disposition of your body will be ignored. By preparing a written Anatomical Gift, you can rest assured that your desire to donate your organs will be carried out. This kit proFindLegalForms.com Information Donation Pursuant to the Uniform Anatomical Gift Act (by Living Donor) No one likes considering their own death, but by avoiding the subject, it is likely that many of y VermontVermont ________ n whose name is subscribed to this instrument appears to be of sound mind and under no duress, fraud, or undue influence. _____________________________ Notary Public My commission expires ____________ersonally and, under oath, stated that he or she is the person described in the above document and he or she signed the above document in my presence. I declare under penalty of perjury that the perso_________________________________ Notary Acknowledgment (Optional) State of ____________________ County of ____________________ On ____________________, ______________________________ came before me pignature of Donor ______________________________ Printed Name of Donor Address: ____________________________________________ City: _______________________________________________ State: ______________y written revocation of my Anatomical Gift. This statement will be delivered to all specified donees, if any, to whom a document of gift had been previously delivered. ______________________________ Sication during a terminal illness or injury addressed to a physician or surgeon; or (4) the delivery of a signed statement to a specified donee to whom a document of gift had been delivered. This is m of this state, a donor may amend or revoke an anatomical gift, not made by will, only by: (1) a signed statement; (2) an oral statement made in the presence of two individuals; (3) any form of commun__________________, I, ______________________________, the donor, fully and completely revoke the Anatomical Gift dated __________________________. Pursuant to Uniform Anatomical Gift Act and the lawsft Act, you should check the laws of your state to determine whether there are any other requirements you must meet to revoke your Anatomical Gift. Revocation of Anatomical Gift On this date ________estroy the original and all copies of your Anatomical Gift or cross out each page of the forms and mark "REVOKED" across them in bold print. Although most states have adopted the Uniform Anatomical Giorm notarized. You should also make certain that a copy of any revocation is provided to anyone who has a copy of your original Anatomical Gift, including any designated donees. You should also then dted. When you have completed the form and printed it, sign the form and make certain that you store the original where you had stored the original of your Anatomical Gift. You may choose to have the f. An anatomical gift that is not revoked by the donor before death is irrevocable and does not require the consent or concurrence of any person after the donor's death. Complete the information requesm of communication during a terminal illness or injury addressed to a physician or surgeon; or (4) the delivery of a signed statement to a specified donee to whom a document of gift had been deliveredn of Anatomical Gift form. A donor may amend or revoke an anatomical gift, not made by will, only by: (1) a signed statement; (2) an oral statement made in the presence of two individuals; (3) any foray out of the use of these materials. An attorney should be consulted for all serious legal matters. Revoking Your Anatomical Gift Instructions Following these instructions, you will find a Revocatios of use, data, or profits; or business interruption) however caused and on any theory of liability, whether in contract, strict liability, or tort (including negligence or otherwise) arising in any w the forms, be responsible or liable for any direct, indirect, incidental, special, exemplary, or consequential damages (including, but not limited to, procurement of substitute goods or services; loserials for your particular needs. The materials are used at your own risk. In no event will: i) FindLegalForms, Inc, its agents, partners, or affiliates, or ii) the providers, authors or publishers ofand Terms of Use" found at findlegalforms.com. These materials are provided "AS-IS." We do not give any express or implied warranties of merchantability, suitability or completeness for any of the matlaimer No Attorney-Client relationship is created by use of these materials. FindLegalForms, Inc. does not provide legal advice. The purchase and use of these materials is subject to the "Disclaimers esigned to fulfill the requirements of the Uniform Anatomical Gift Act. Included in this kit is the following: General Instructions for Revoking Your Anatomical Gift Revocation of Anatomical Gift Discnt to revoke the document. Until your death, it is your right to revoke your Anatomical Gift at any time. This kit provides tools and guidelines to assist you in revoking your Anatomical Gift and is dFindLegalForms.com Information Revoking an Anatomical Gift (Organ Donation Revocation) You prepared a written Anatomical Gift, but now because of a change of circumstances or a change of heart, you wa VermontVermont _____________ Name of Survivor: _______________________________ Address: ____________________________________________ City: _______________________________________________ State: __________________________________urposes (strike any of the following you do not want): (1) Transplant (2) Therapy (3) Research (4) Education Date: __________________ Signature of Survivor: __________________________________ Printed_______________ ________________________________________________________________________ ________________________________________________________________________ III. The gift is for the following pthe applicable box): Give any needed organs, tissues, or parts, OR Give the following organs, tissues, or parts only: _______________________ _________________________________________________________ity and state). I. I survive the decedent as (mark the appropriate box): spouse; adult son or daughter; parent; adult brother or sister; grandparent; or guardian of the decedent. II. I hereby (mark this anatomical gift from the body of __________________________________(name of decedent) who died on _____________, 20___ at_______________________________ in ____________________________________ (corney should be consulted for all serious legal matters. Anatomical Gift by Next of Kin or Guardian of the Person Pursuant to the Uniform Anatomical Gift Act and the law of this state, I hereby make rruption) however caused and on any theory of liability, whether in contract, strict liability, or tort (including negligence or otherwise) arising in any way out of the use of these materials. An att direct, indirect, incidental, special, exemplary, or consequential damages (including, but not limited to, procurement of substitute goods or services; loss of use, data, or profits; or business inteals are used at your own risk. In no event will: i) FindLegalForms, Inc, its agents, partners, or affiliates, or ii) the providers, authors or publishers of the forms, be responsible or liable for anym. These materials are provided "AS-IS." We do not give any express or implied warranties of merchantability, suitability or completeness for any of the materials for your particular needs. The materieated by use of these materials. FindLegalForms, Inc. does not provide legal advice. The purchase and use of these materials is subject to the "Disclaimers and Terms of Use" found at findlegalforms.con for the removal of a part from the body of the decedent, the physician, surgeon, technician, or enucleator removing the part knows of the revocation. Disclaimer No Attorney-Client relationship is cr a member of the person's class or a prior class. An anatomical gift by a person authorized under subdivision may be revoked by any member of the same or a prior class if, before procedures have beguoposing to make an anatomical gift knows of a refusal or contrary indications by the decedent. (3) The person proposing to make an anatomical gift knows of an objection to making an anatomical gift byAn anatomical gift may not be made by a person listed above if any of the following occur: (1) A person in a prior class is available at the time of death to make an anatomical gift. (2) The person pre decedent; (3) either parent of the decedent; (4) an adult brother or sister of the decedent; (5) a grandparent of the decedent; and (6) a guardian of the person of the decedent at the time of death ker for an authorized purpose, unless the decedent, at the time of death, has made an unrevoked refusal to make that anatomical gift: (1) the spouse of the decedent; (2) an adult son or daughter of th Gift Form An anatomical gift may be made any member of the following classes of persons, in the order of priority listed, may make an anatomical gift of all or part of the decedent's body or a pacemas made on behalf of the decedent by the next of kin or guardian. Included in this kit are the following: General Instructions for preparing your Anatomical Gift (by next of kin or guardian) Anatomicalt. As the next of kin or guardian, you can prepare and execute an Anatomical Gift on behalf of the decedent. This kit is designed to fulfill the obligations of the Uniform Anatomical Gift Act for giftFindLegalForms.com Information Donation Pursuant to the Uniform Anatomical Gift Act (by Next of Kin or Guardian) A loved one has died and you believe that he/she would desire to make an Anatomical Gif Vermont