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West Virginia __ Notary Public 2 d the same before me. Given under my hand this ______ day of ______, 20__. My commission expires:______________________________________ _______________________________________________________________________________________________________________________, as witnesses, whose names are signed to the writing above bearing date on the _______________ day of _______, 20____,have this day acknowledge of said County, do certify that ___________________________________________________________________, as principal, and _________________________________________________________________ and ____________________________ Date:_________________________________________ STATE OF WEST VIRGINIA _______________________________ COUNTY OF ) ) ) ) I, ______________________________________, a Notary Public________ _____________________________________________ (Witness Signature) Print Name: ___________________________________ Address: ______________________________________ Phone: _____________________Witness Signature) Print Name: ___________________________________ Address: ______________________________________ Phone: _______________________________________ Date:_________________________________ian or the principal's medical power of attorney representative or successor medical power of attorney representative under a medical power of attorney. _____________________________________________ (of the principal to the best of my knowledge under any will of principal or codicil thereto, or directly financially responsible for principal's medical care. I am not the principal's attending physicincipal's signature above for or at the direction of the principal. I am at least eighteen years of age and am not related to the principal by blood or marriage, entitled to any portion of the estate ____________________________ Signed _________________________________________________________________ _________________________________________________________________ Address 1 I did not sign the pr my legal right to refuse medical or surgical treatment and accept the consequences resulting from such refusal. I understand the full import of this living will. _______________________________________________________________________________ _____________________________________________________________________________ It is my intention that this living will be honored as the final expression oftments.) _____________________________________________________________________________ _____________________________________________________________________________ ___________________________________chines, cardiopulmonary resuscitation, dialysis and mental health treatment may be placed here. My failure to provide special directives or limitations does not mean that I want or refuse certain treay to keep me comfortable. I want to receive as much medication as is necessary to alleviate my pain. I give the following SPECIAL DIRECTIVES OR LIMITATIONS: (Comments about tube feedings, breathing maong the dying process or maintain me in a persistent vegetative state be withheld or withdrawn. I want to be allowed to die naturally and only be given medications or other medical procedures necessarrsistent vegetative state (I am unconscious and am neither aware of my environment nor able to interact with others), I direct that life-prolonging medical intervention that would serve solely to proling circumstances: If I am very sick and not able to communicate my wishes for myself and I am certified by one physician, who has personally examined me, to have a terminal condition or to be in a pee my wishes for myself. In the absence of my ability to give directions regarding the use of life-prolonging medical intervention, it is my desire that my dying shall not be prolonged under the follow_____________________________________________________________, being of sound mind, willfully and voluntarily declare that I want my wishes to be respected if I am very sick and not able to communicatsubject to the Disclaimers and Terms of Use found at findlegalforms.com STATE OF WEST VIRGINIA Living Will Living will made this _____________________day of _____________________(month, year). I,__commended 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 forms is 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 always repose 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 the directions in the living will are severable. [_] 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 purany of the other specific directions be held to be invalid, such invalidity shall not affect other directions of the living will which can be given effect without the invalid direction and to this end unauthorized practice of law. (g) The living will may, but need not, be in the following form and may include other specific directions not inconsistent with other provisions of this article. Should agencies, senior citizens centers, hospitals, nursing homes, personal care homes, community care facilities or any other similar person or group, without separate compensation, does not constitute thewill. (f) The provision of living will or medical power of attorney forms substantially in compliance with this article by health care providers, medical practitioners, social workers, social service ch forms if the person desires: Provided, That under no circumstances may admission to a health care facility be predicated upon a person having completed either a medical power of attorney or living admission to any health care facility, each person shall be advised of the existence and availability of living will and medical power of attorney forms and shall be given assistance in completing suing will or medical power of attorney, shall make the living will, medical power of attorney or a copy of either or a revocation of either a part of the principal's medical records. (e) At the time oftion of the living will or medical power of attorney. An attending physician or other health care provider, when presented with the living will or medical power of attorney, or the revocation of a liv or his or her representative to provide for notification to his or her attending physician and other health care providers of the existence of the living will or medical power of attorney or a revoca operator of a health care facility serving the principal and who is not related to the principal. Living Will Information & Instructions ­ Page 2 (d) It shall be the responsibility of the principal principal; (2) an employee of a treating health care provider not related to the principal; (3) an operator of a health care facility serving the principal; or (4) any person who is an employee of an representative. (c) The following persons may not serve as a medical power of attorney representative or successor medical power of attorney representative: (1) A treating health care provider of the; (4) Directly financially responsible for principal's medical care; (5) The attending physician; or (6) The principal's medical power of attorney representative or successor medical power of attorney medical power of attorney shall not be affected when a witness at the time of witnessing such living will or medical power of attorney was unaware of being a named beneficiary of the principal's will to the principal by blood or marriage; (3) Entitled to any portion of the estate of the principal under any will of the principal or codicil thereto: Provided, That the validity of the living will orction (d) of this section. (b) In addition, a witness may not be: (1) The person who signed the living will or medical power of attorney on behalf of and at the direction of the principal; (2) Related two or more witnesses at least eighteen years of age; and (5) signed and attested by such witnesses whose signatures and attestations shall be acknowledged before a notary public as provided in subseexecuted by the principal or by another person in the principal's presence at the principal's express direction if the principal is physically unable to do so; (3) dated; (4) signed in the presence ofney. (a) Any competent adult may execute at any time a living will or medical power of attorney. A living will or medical power of attorney made pursuant to this article shall be: (1) In writing; (2) q. of the West Virginia Code. For your convenience, we have included useful excerpts from the West Virginia Codes relating to Living Wills. §16-30-4. Executing a living will or medical power of attoriving Will This package contains (1) Information and Instruction for West Virginia Living Will; (2) West Virginia Living Will. This West Virginia Living Will is based on Chapter 16 Section 30-4 et. Se____, 20____. My commission expires:______________________________________ __________________________________________________________ Notary Public -3- Information and Instructions West Virginia Lmes are signed to the writing above bearing date on the ____________ day of _____________, 20_____, have this day acknowledged the same before me. Given under my hand this __________ day of ________________________________, a Notary Public of said County, do certify that_________________________________________, as principal, and ____________________ and __________________, as witnesses, whose na_______ _____________________________________________ (Witness Signature) Print Name: ___________________________________ STATE OF WEST VIRGINA COUNTY OF _______________________________ I, _________ _______________________________________ _____________________________________________ (Witness Signature) Print Name: ___________________________________ -2- Dated: ________________________________ally responsible for the costs of the principal's medical or other care. I am not the principal's attending physician, nor am I the representative or successor representative of the principal. Dated:related to the principal by blood or marriage. I am not entitled to any portion of the estate of the principal or to the best of my knowledge under any will of the principal or codicil thereto, or legMED CONSENT TO MY OWN MEDICAL CARE. __________________________________________ (Principal's Signature) I did not sign the principal's signature above. I am at least eighteen years of age and am not _______ _____________________________________________________________________________ THIS MEDICAL POWER OF ATTORNEY SHALL BECOME EFFECTIVE ONLY UPON MY INCAPACITY TO GIVE, WITHHOLD OR WITHDRAW INFOR___________________________________________________ _____________________________________________________________________________ ______________________________________________________________________vide special directives or limitations does not mean that I want or refuse certain treatments.) _____________________________________________________________________________ __________________________TIONS ON THIS POWER: (Comments about tube feedings, breathing machines, cardiopulmonary resuscitation, dialysis, funeral arrangements, autopsy and organ donation may be placed here). My failure to proho rity under this medical power of attorney, my representative shall act consistently with my special directives or limitations as stated below. I am giving the following SPECIAL DIRECTIVES OR LIMITAformal statement of my desire concerning the method by which any health care -1- decisions should be made on my behalf during any period when I am unable to make such decisions. In exercising the autnot be the subject of review by any health care provider or administrative or judicial agency. It is my intent that this document be legally binding and effective and that this document be taken as a intent that my family, my physician and all legal authorities be bound by the decisions that are made by the representative appointed by this document and it is my intent that these decisions should t to carry into effect the health care decisions that I would make if I were able to do so and because I also believe that this person will act in my best interest when my wishes are unknown. It is my limited to, decisions regarding the withholding or withdrawal of lifeprolonging interventions. I appoint this representative because I believe this person understands my wishes and values and will ac diagnostic procedures, or autopsy if my representative determines that I, if able to do so, would consent to, refuse or withdraw such treatment or procedures. Such authority shall include, but not bes document is specifically authorized to be granted access to my medical records and other health information and to act on my behalf to consent to, refuse or withdraw any and all medical treatment org to medical treatment, surgical treatment, nursing care, medication, hospitalization, care and treatment in a nursing home or other facility, and home health care. The representative appointed by thi__________________ Address: ______________________________________ Phone: _______________________________________ This appointment shall extend to, but not be limited to, health care decisions relatin choose as my successor representative is (Insert the name, address, area code and telephone number of the person you wish to designate as your successor representative): Print Name: ____________________________________ Address: ______________________________________ Phone: _______________________________________ If my representative is unable, unwilling or disqualified to serve, then the person I myself. The person I choose as my representative is (Insert the name, address, area code and telephone number of the person you wish to designate as your representative): Print Name: _____________________________, (name and address ) hereby appoint my representative to act on my behalf to give, withhold or withdraw informed consent to health care decisions in the event that I am not able to do sosclaimers and Terms of Use found at findlegalforms.com -2- STATE OF WEST VIRGINIA MEDICAL POWER OF ATTORNEY Dated: _____________________________ , 20______ I,_______________________________________t is negotiated with 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 Dith an attorney first. Before using or signing this document you should have an attorney review it to make sure it fits your particular situation. You should also consult an attorney whenever a documen 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 without consulting wis" 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 intended andt affect other directions of the living will which can be given effect without the invalid direction and to this end the directions in the living will are severable. [_] These forms are provided "as iowing form and may include other specific directions not inconsistent with other provisions of this article. Should any of the other specific directions be held to be invalid, such invalidity shall nommunity care facilities or any other similar person or group, without separate compensation, does not constitute the unauthorized practice of law. (g) The living will may, but need not, be in the folllly in compliance with this article by health care providers, medical practitioners, social workers, social service agencies, senior citizens centers, hospitals, nursing homes, personal care homes, coto a health care facility be predicated upon a person having completed either a medical power of attorney or living will. (f) The provision of living will or medical power of attorney forms substantiae and availability of living will and medical power of attorney forms and shall be given assistance in completing such forms if the person desires: Provided, That under no circumstances may admission attorney or a copy of either or a revocation of either a part of the principal's medical records. (e) At the time of admission to any health care facility, each person shall be advised of the existenclth care provider, when presented with -1- the living will or medical power of attorney, or the revocation of a living will or medical power of attorney, shall make the living will, medical power of an and other health care providers of the existence of the living will or medical power of attorney or a revocation of the living will or medical power of attorney. An attending physician or other heaving the principal and who is not related to the principal. (d) It shall be the responsibility of the principal or his or her representative to provide for notification to his or her attending physicing health care provider not related to the principal; (3) an operator of a health care facility serving the principal; or (4) any person who is an employee of an operator of a health care facility serons may not serve as a medical power of attorney representative or successor medical power of attorney representative: (1) A treating health care provider of the principal; (2) an employee of a treatifor principal's medical care; (5) The attending physician; or (6) The principal's medical power of attorney representative or successor medical power of attorney representative. (c) The following pers affected when a witness at the time of witnessing such living will or medical power of attorney was unaware of being a named beneficiary of the principal's will; (4) Directly financially responsible (3) Entitled to any portion of the estate of the principal under any will of the principal or codicil thereto: Provided, That the validity of the living will or medical power of attorney shall not beion, a witness may not be: (1) The person who signed the living will or medical power of attorney on behalf of and at the direction of the principal; (2) Related to the principal by blood or marriage; years of age; and (5) signed and attested by such witnesses whose signatures and attestations sha ll be acknowledged before a notary public as provided in subsection (d) of this section. (b) In additperson in the principal's presence at the principal's express direction if the principal is physically unable to do so; (3) dated; (4) signed in the presence of two or more witnesses at least eighteen at any time a living will or medical power of attorney. A living will or medical power of attorney made pursuant to this article shall be: (1) In writing; (2) executed by the principal or by another ts from the West Virginia Code relating to the West Virginia Power of Attorney for Health Care Form. §16-30-4. Executing a living will or medical power of attorney. (a) Any competent adult may executeh Care Form (Medical Power of Attorney). This West Virginia Power of Attorney for Health Care is based on Chapter 16 Section 16-30-4 et. Seq. of the West Virginia Code. The following are useful excerpney for Health Care This package contains (1) Information and Instruction for West Virginia Power of Attorney for Health Care (Medical Power of Attorney); (2) West Virginia Power of Attorney for Healtld 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 and Instructions Power of Attorke 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 shou 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 without consulting an attorney first to marranties 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 as 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 waWest Virginia Advance Health Care Directive This package contains both a West Virginia Power of Attorney for Health Care and a West Virginia Living Will. Together these forms are also sometimes known West Virginia