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Doe Family Will

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  • 1. Doe Family Last Will & Testament – Package – File# 183051 – Electronic Signatures Verification Status – ALL APPLICABLE DOCUMENTS NOT "ESIGNED" (See Electronic Signature Page) ~ Provided By ~ MY LIFECARD PLAN 7373 E. Doubletree Ranch Rd., #200 Scottsdale, AZ 85258 www.MYLIFECARDPLAN.com
  • 2. PDF/2 GENERAL INSTRUCTIONS / IMPLEMENTATION Congratulations on your purchase! You have taken the first steps to help (i) enable specific proxy management of your assets in your stead, and (ii) ensure your medical (emergency) preparedness. Now you will need to properly implement your plan. Enclosed are the documents that comprise your – Last Will & Testament Package As you conduct a general review of the documents, search for the pages that must be signed by you and your Witnesses and a Notary Public. Below is a checklist of the pages that should be signed and implemented immediately. PLEASE NOTICE: A SHADED CHECKED BOX is positioned at the lower right hand corner of the (twenty/20) pages where either (a) each of you have to sign, (b) the Notary Public has to sign, (c) witnesses enter their names and sign, and/or (d) the current date is to be entered. The "Portable Document Format" / PDF page numbers posted to the right (>) of the document page numbers (listed below) locate the "signature page(s)" of each document stored in your electronic (Last Will & Testament Package) PDF file. (NOTE: The Agent Notices are not to be signed until the time they are to be used.)  Last Will & Testament(s) / Pages 13 & 14 > PDF/15-16&31-32  Durable Power(s) of Attorney / Assets / Page(s) 3 & 4 > PDF/37,38&41,42  Durable Power(s) of Attorney for Health Care / Page(s) 4 > PDF/48&52  Advanced Health Care Directive(s) / Page(s) 8 > PDF/63&73  Durable HIPAA Statement(s) / Pages 1 & 2 > PDF/64-65&74-75  Pro-Life Living Will(s)* / Pages 1 & 2 > PDF/76-77&78-79  Living Will Declaration(s) / Page(s) 3 > PDF/81,82&84,85 *The "Pro-Life" Living Will states that the Declarant does not want to be denied hydration and/or tube feeding – under any circumstances. Be advised that such a signed declaration may be deemed to be in conflict with a regular Living Will Declaration and/or other entries you may make in your Advanced Directives. NOTICE: The instructional information contained in this Last Will & Testament Package is for reference ONLY, and is not intended to replace legal, tax planning, or personal health care counsel. You should obtain independent counsel before acting on any directives or other information described herein.
  • 3. PDF/3 LAST WILL AND TESTAMENT JOHN W. DOE I, JOHN W. DOE, a resident of Maricpoa County, State of Arizona, declare that this is my Last Will and Testament. I hereby revoke all my previous Wills and codicils. ARTICLE I – Introductory Provisions – Marital Status. 1.1. I am married to JANE E. DOE and all references in this Will to my spouse are to JANE E. DOE. Identification of Living Children. 1.2. The name(s) of the primary beneficiary(s) of my Will who shall receive of my probate estate – if my spouse does not survive me – accordingly as such dispositive terms are prescribed in Sections 3.4/3.5 (below) is/are: JAMES G. DOE & JOYCE L. DOE Children Defined. 1.3. All references to “child” or “children” are to the child or children as may be listed in Section 1.2 (above), and including any child or children subsequently born to or legally adopted by me after the date of this Will. ARTICLE II – Personal Property Allocations – Tangible Personal Property. 2.1. I give all of my tangible personal property, including my interest in any insurance on that property (if any), to my spouse. However, if my spouse does not survive me and there are no entries on such Personal Property Allocations page, then my personal property shall be distributed as provided in Sections 3.4 – 3.8 of this Will. LW&T Page 1 (of 14)
  • 4. PDF/4 2.2. If my spouse does not survive me and the beneficiaries of my Will are not able to agree on the division and distribution of my tangible personal property and there are no entries in the Personal Property Allocations page, in such case, then my Executor shall divide and allocate the property as the Executor believes to be in accordance with my wishes. The decision(s) of the Executor thereof shall be deemed valid, complete and final. Specific Gifts. 2.3. Notwithstanding Section 2.1 and 2.2 (above), if I have made any handwritten entries on the Directive of Specific Personal Property Allocations (Page 11 of 13) with my signature thereon, then the specific allocations of such Directive shall apply concerning specific gifts of my personal property. ARTICLE III – Balance of My Probate Estate – Disposition of My Probate Estate if My Spouse Survives Me. 3.1. I give the residue of my entire estate to my spouse, JANE E. DOE. Disposition Eligibility for Marital Deduction. 3.2. I intend that the disposition in the preceding section be eligible for the federal estate tax marital deduction, and that this instrument shall be construed accordingly. No fiduciary under this Will shall take any action or exercise any power that may impair the federal estate tax marital deduction. If My Spouse Does Not Survive Me or Disclaims. 3.3. If my spouse does not survive me – or shall disclaim all or any part prescribed to my spouse herein where any such disclaimed interest shall be part (or all) of the residue of my probate estate – then I give the residue of my probate estate pursuant to Sections 3.4 – 3.9, as follows: (See Section 3.4/3.5 Estate Allocation Terms on Following Page) LW&T Page 2 (of 14)
  • 5. PDF/5 Division of My Probate Estate if My Spouse Does Not Survive Me. 3.4. IF MY SPOUSE DOES NOT SURVIVE ME, my Executor shall divide my probate estate into as many portions of equal market value as are necessary to create one (1) equal share for each beneficiary named in Section 1.2 (supra). 3.5. My Executor shall then distribute said equal shares outright respectively to each of the beneficiaries identified in Section 1.2, or otherwise according to certain Specific Directives that may be prescribed in Section 3.6 (below). (a) Contingent Distributions. If any beneficiary named in Section 1.2, who is then living at the time of the execution of my Will, does not survive me then such deceased beneficiary's portion shall be distributed EQUALLY TO HIS (HER) SURVIVING LEGAL CHILDREN/ISSUE, BY RIGHT OF REPRESENTATION. And, if any such beneficiary does not survive me and leaves no surviving children/issue, in such case, then that decedent beneficiary's portion shall be distributed equally to the other surviving beneficiaries listed in Section 1.2 (or as otherwise may be prescribed in Section 3.6, below). (b) Notwithstanding the provisions as defined above, sub-paragraph “(e)” (listed below) contains a Schedule of Other/Alternate Primary Beneficiaries which is a list of beneficiaries (if any) and the percentages of my probate estate that each respective beneficiary listed therein shall receive prior to the allocations and distributions prescribed in Sections 1.2 & 3.4/3.5. (c) In such case of the usage of the Schedule of Other/Alternate Primary Beneficiaries, the allocations in Sections 1.2 & 3.4/3.5 shall be deemed to be allocations of the remainder of my probate estate remaining after the allocations/distributions prescribed in sub-paragraphs “(d)” & “(e)” (and/or under Section “3.6” / by Special Directives, if applicable) or shall be deemed as the "Alternate Distribution Schedule” concerning my Will if the beneficiaries listed thereof are to receive all – that is, a one hundred percent (100%) aggregate – of my probate estate. LW&T Page 2 (of 13)
  • 6. PDF/6 (d) If any beneficiary listed in sub-paragraph (e) does not survive me then such decedent person’s designated portion shall be allocated to those other beneficiaries listed there in prorata portions of the aggregate percentage of my probate estate allocated below – unless other provided in Section 3.6 (below): (e) Schedule of Other / Alternate Primary Beneficiaries: _________________________________ / _______% Beneficiary Name _________________________________ / _______% Beneficiary Name _________________________________ / _______% Beneficiary Name _________________________________ / _______% Beneficiary Name _________________________________ / _______% Beneficiary Name _________________________________ / _______% Beneficiary Name _________________________________ / _______% Beneficiary Name (f) Notwithstanding the above, in the event that any beneficiary of my probate estate is then a debtor to me – verified by a written instrument of debt – at the time of my decease then the following shall apply: (i) the share of such indebted beneficiary shall be decreased by a certain formula amount that is equal to the total outstanding value of debt(s) such person owed me, which amount is then (ii) multiplied by a percentage that corresponds to the value of my probate estate (including the value of the debt[s] owed to me) – that such indebted person is not entitled to receive which shall be referred to as the percentage amount; wherein, (iii) such formulated percentage amount shall be subtracted from such indebted person’s share and added prorata to the portion(s) distributable to the other beneficiary(s) of my probate estate who are then living. (g) The following identified person(s) has/have been intentionally disinherited and is/are not to receive any portion(s) of my Will: _______________________________________________________________ _______________________________________________________________ LW&T Page 4 (of 14)
  • 7. PDF/7 Alternate and/or Additional Specific Directives of This Will. NOTICE: Use space below to enter other terms/directives that you want mandated through your Will including but not limited to allocations, if any, to (other) beneficiaries for distributions of "in cash" and/or "in kind": 3.6. The following terms shall ADDITIONALLY apply as to or in place of the administrative and/or allocation terms and/or decrees of my Will notwithstanding any provisions otherwise prescribed anywhere herein to the contrary. Any allocations to beneficiaries prescribed below – whether in cash and/or in kind and/or in unequal percentage amounts – shall be deemed and administrated as part of the Schedule of Other/Alternate Primary Beneficiaries with respect to the terms of allocation/administration prescribed above: _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ < < < End of Section 3.5 > > > Beneficiary Under Age 21. 3.7. If a beneficiary of this Will is under twenty-one (21) years of age, or otherwise deemed as dependent, then my Executor shall establish a “trust” for such beneficiary and pay to or apply for the benefit of such beneficiary, in Executor’s discretion, as much of the income of that beneficiary’s said trust as deemed necessary for his/her health, support, maintenance and education. If my Executor deems the income to be insufficient, he/she may also pay to or apply for the benefit of such beneficiary as much of the principal of beneficiary’s trust as my Executor, in his/her unhindered discretion, deems necessary for the beneficiary’s health, support, maintenance and education. My Executor, in lieu of making direct payments to the beneficiary, may make payments to the beneficiary’s conservator or guardian, to the beneficiary’s custodian under the Uniform Gifts to Minors Act or Uniform Transfers to Minors Act of any state, to one or more suitable persons as my Executor deems proper, or to accounts in the beneficiary’s name with financial institutions. LW&T Page 5 (of 14)
  • 8. PDF/8 Beneficiary Over Age 21. 3.8. If beneficiary of this Will is twenty-one (21) years of age or older, then my Executor shall distribute the balance of the net income and principal of that beneficiary’s allocated trust/portion(s) outright to him/her as soon as administratively possible. Notwithstanding, my Executor may arbitrarily hold any such beneficiary's portion IN TRUST for a later outright distribution period if such action is deemed prudent as it would pertain to that beneficiary's best interest in consideration of all then existing circumstances, and would therefore administer any such beneficiary's portion for his/her benefit per those terms prescribed in Sections 3.4/3.5/3.6 (above). Final Distribution. 3.9. If, under the foregoing provisions, a portion of my estate shall be undisposed of, then such non-disposed portion shall be distributed to my legal heirs whose identity(s) and respective share(s) shall be determined as though my death had occurred immediately following the happening of the event requiring distribution of such undisposed portion of my estate, and according to the laws of succession then in force in the State of Arizona. ARTICLE IV – Nominated Executor – Nomination of Executor. 4.1. I nominate my spouse, JANE E. DOE, as Executor of my Will. Successor Executors. 4.2. If my spouse is unable or unwilling to serve or continue as Executor of my Will, then I nominate JAMES G. DOE to serve as my Executor. If JAMES G. DOE is unable or unwilling to serve or continue as the Executor of my Will, in such case, then I nominate JOYCE L. DOE to serve. Waiver of Bond. 4.3. No bond or undertaking shall be required of any Executor nominated herein. LW&T Page 6 (of 14)
  • 9. PDF/9 General Powers of My Executor. 4.4. I authorize but do not direct my Executor to sell any property belonging to my estate, either with or without notice. My Executor is further authorized to invest and reinvest any surplus money, in any kind of property, real, personal, or mixed, and every kind of investment, specifically including, but not limited to, interest-bearing accounts, corporate obligations of every kind, preferred or common stocks, shares of investment trusts, investment companies, mutual funds, or common trust funds, including funds administered by the Executor, and mortgage participations, that persons of prudence, discretion and intelligence acquire for their own account, and to either continue the operation of any business belonging to my estate for such time and in such manner as it may deem advisable and for the best interest of my estate, or to sell or liquidate said business at such time and upon such terms as my Executor may deem advisable and for the best interest of my estate; and any such operation, sale or liquidation shall be at the risk of my estate and without liability on the part of my Executor for any losses resulting therefrom. Independent Administration Permitted. 4.5. My Executor shall have all powers now or hereafter conferred on Executors by law then in force in the State of Arizona except as otherwise specifically provided in this Will, including any powers enumerated in this Will. Division or Distribution in Cash or Kind. 4.6. In order to satisfy a pecuniary gift or to distribute or divide assets into shares or partial shares, the Executor may distribute or divide those assets in kind, or divide undivided interests in those assets, or sell all or any part of those assets and distribute or divide the property in cash, in kind, or partly in cash and partly in kind. Property distributed to satisfy a pecuniary gift under this instrument shall be valued at its fair market value at the time of distribution. Power to Make Tax Elections. 4.7. To the extent permitted by law, and without regard to the resulting effect on any other provision of this Will, on any person interested on the amount of taxes that may be payable, my Executor shall have the power to elect an alternative valuation date for estate tax purposes; choose the methods to pay any death taxes; elect to treat or use any item for state or federal estate or income tax purposes as an income tax deduction or an estate tax deduction; disclaim all or any portion of any interest in property passing to my estate at or after my death; and determine when an item is to be treated as taken into income or used as a tax deduction. LW&T Page 7 (of 14)
  • 10. PDF/10 ARTICLE V – Nominated Guardian – Nomination of Guardian and Successor. (Not Applicable to this Will) Waiver of Bond. 5.2. No bond or undertaking shall be required of any guardian as nominated (per Section 5.1) in this Will. Powers of Guardian(s). 5.3. It is my intent that any guardian nominated in this Will shall have the same authority with respect to the person of the ward as a parent having legal custody of a child would have. It is my intent that all powers granted to guardians named herein may be exercised without unnecessary court authorization. ARTICLE VI – Concluding Provisions – Debts, Taxes and Expenses. 6.1. All of my funeral, last illness, administration expenses and death taxes, shall be paid out of the residue of my estate, subject, however, to the provisions below. Payment of Debt. 6.2. Except for any indebtedness that I may have to any qualified pension, profit sharing or similar plan (other than loans against a voluntary contribution account), which indebtedness shall be promptly paid following my death, the provisions of this Will shall not operate to accelerate any liability; and all indebtedness of mine for which any properties or insurance policies stand as collateral security shall remain an encumbrance upon the same, which shall pass subject to such indebtedness without reimbursement of any kind from my estate. LW&T Page 8 (of 14)
  • 11. PDF/11 Payment of Death Taxes. 6.3. The Executor shall pay death taxes, whether or not attributable to property inventoried in my probate estate, by prorating and apportioning them among the persons having an interest in my estate according to the apportionment provisions as described under Section 2207 of the Internal Revenue Code. Definition of Death Taxes. 6.4. The term “death taxes” as used in this Will, shall mean all inheritance, estate, succession, and other similar taxes that are payable by any person on account of that person’s interest in my estate or by reason of my death, including penalties and interest, but excluding the following: (a) Any (other) additional tax – not described above – that may be assessed in my estate shall be paid by those trusts and/or beneficiaries who receive the assets upon which the additional tax is assessed. (b) Any federal or state tax imposed on a generation-skipping transfer, as that term is defined in the federal tax laws, shall be paid by those trusts and/or beneficiaries who receive the assets upon which the additional tax is assessed. Simultaneous Death. 6.5. If any beneficiary under this Will and I die simultaneously, or if it cannot be established by clear and convincing evidence whether that beneficiary or I died first, I shall be deemed to have survived that beneficiary, and this Will shall be construed accordingly. Period of Survivorship. 6.6. For the purposes of this Will, a beneficiary shall not be deemed to have survived me if that beneficiary dies within thirty (30) days after my death. No-Contest Clause. 6.7. If any heir, devisee, legatee or beneficiary under this Will, or any of my heirs or any person claiming under this Will, my estate, or any trust established by me, whether directly or indirectly, singly or in conjunction with any other person commits any of the actions listed in this Section (et seq.), then all legacies, bequests, devises and interests given under this Will to that person shall be forfeited as though he or she predeceased me without surviving issue: LW&T Page 9 (of 14)
  • 12. PDF/12 (a) Contests or otherwise objects in any court to the validity of this Will, or any share or subtrust created by this Will, or any beneficiary designation account signed by me; (b) Files suit on a creditor’s claim filed in a probate of my estate, or a creditor’s claim on any other document, after rejection or lack of action by the respective fiduciary; (c) Claims ownership to any asset held in joint tenancy by me, other than as a surviving joint tenant; (d) Files a petition for family allowance in a probate of my estate; or brings, joins or is a party to a petition for settlement or for compromise affecting the terms of this instrument; (e) Object in any manner to any action taken or proposed to be taken in good faith by the Executor of my estate or the Executor of any of my trusts (including, without limitation, the good faith exercise or non-exercise of a discretion granted to the Executor or Executor), whether said Executor or Executor is acting under court order, notice of proposed action or otherwise; or, (f) Successfully or unsuccessfully attacks or seeks to impair or invalidate any of the following: any designation of beneficiaries for any insurance policy on my life; any trust which I have created during my lifetime; or any gift which I have made during my lifetime. Expenses. 6.8. Expenses to resist any contest or other attack of any nature upon my estate shall be paid from my estate as expenses of administration. Severable. 6.9. In the event that any provision of this Will is held to be invalid, void or illegal, the same shall be deemed severable from the remainder of the provisions of this Will, and shall in no way affect, impair or invalidate any other provision in this Will. If such provision shall be deemed invalid due to its scope and breadth as described in this Will, such provision shall be deemed valid to the extent of the scope or breadth permitted by law. LW&T Page 10 (of 14)
  • 13. PDF/13 Perpetuities Savings Clause. 6.10. Notwithstanding any other provision of this Will, unless otherwise allowed by applicable state law, every trust created by this Will shall terminate no later than twenty-one (21) years after the death of the last survivor of my issue and the beneficiaries of this Will who are alive at my death. If a trust is terminated under this section of the Will, the Executor shall distribute all of the principal and undistributed income of the trust to the income beneficiaries of that trust in proportion to which they are entitled (or eligible, in the case of discretionary payments) to receive immediately before the termination. If that proportion is not fixed by the terms of this Will, the Executor shall distribute all of the trust property to the persons then entitled or eligible to receive income from the trust outright in a manner that, in the Executor’s opinion, shall give effect to my intent in creating the trust(s). The Executor’s decision is to be final and incontestable by anyone. Severability Clause. 6.11. In the event that any provision of this Will is held to be invalid, void or illegal, the same shall be deemed severable from the remainder of the provisions of this Will and shall in no way affect, impair or invalidate any other provision in this Will. If such provision shall be deemed invalid due to its scope and breadth, such provision shall be deemed valid to the extent of the scope or breadth permitted by law. Arizona Law to Apply. 6.12. All questions concerning the validity and interpretation of this Will, including any trusts created by this Will, shall be governed by the laws of the State of Arizona in effect at the time this Will is executed. ARTICLE VII – Contents, Testimonial and Attestation Provisions – Signature and Attestation. This Last Will & Testament consists of seven (7) Articles – this Article inclusive – and thirteen (13) pages. Following this (final) Article Seven, Testator’s signature, and the witnesses’ attestations hereof is a self-proving affidavit identified on and listed as Page 14. LW&T Page 11 (of 14)
  • 14. PDF/14 Directive of Specific Personal Property Allocations I, JOHN W. DOE, in accordance with Section 2.3, of Article II, in my Last Will & Testament, hereby bequeath certain tangible personal property of mine to the persons identified below respective of each separate item adjacent to the person’s name. All such entries on this page may only be handwritten in by me. Personal Property Item Recipient _________________________________ ______________________________ _________________________________ ______________________________ _________________________________ ______________________________ _________________________________ ______________________________ _________________________________ ______________________________ _________________________________ ______________________________ _________________________________ ______________________________ _________________________________ ______________________________ _________________________________ ______________________________ x______________________________ JOHN W. DOE LW&T Page 12 (of 14)
  • 15. PDF/15 IN WITNESS WHEREOF, I HAVE HEREUNTO SET MY HAND ON THIS _______ DAY OF ___________________, 2013. x________________________________ JOHN W. DOE Signed, sealed, published and declared by the above named Testator as (and for) his Last Will & Testament in our presence who, at his request, in his presence and in the presence of each other, we have hereunto subscribed our names as witnesses. x________________________________ _________________________________ Witness Address x________________________________ _________________________________ Witness Address STATE OF ARIZONA COUNTY OF MARICPOA On this _______ day of _________________, 2013, before me, _____________________, the undersigned Notary Public, personally appeared JOHN W. DOE, and the above identified witnesses, who proved to me on the basis of satisfactory evidence to be the persons whose names are subscribed to the within instrument and acknowledged to me that they signed the same in their authorized capacity, and that by their signatures executed this instrument. I certify under PENALTY OF PERJURY under the laws of the State of Arizona that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: ______________________________ (Seal) LW&T Page 13 (of 14) 
  • 16. PDF/16 SELF PROVING AFFIDAVIT STATE OF ARIZONA COUNTY OF MARICPOA I, JOHN W. DOE, the Testator of the within, hereby certify that I executed my signature on said Will this ________ day of ___________________, 2013. I further certify that I requested signatures as witnesses to my Last Will & Testament from the following individuals: _______________________________ (and) _______________________________ Witness Name Witness Name x_______________________________ JOHN W. DOE We, __________________________ & _________________________, (the witnesses), being first duly sworn, do depose and say to the undersigned authority that we witnessed the Testator's execution of his Will and that he signed it willingly and that each of us, in the presence and hearing of the Testator, hereby sign herein as witness to his signing, and that to the best of our knowledge he is eighteen years of age or older, of sound mind, under no constraint or undue influence and competent to make testamentary disposition of real and personal property. x________________________________ _________________________________ Witness Address x________________________________ _________________________________ Witness Address On this _______ day of ________________, 2013, before me, ______________________, the undersigned Notary Public, personally appeared JOHN W. DOE, and the above identified witnesses, who proved to me on the basis of satisfactory evidence to be the persons whose names are subscribed to the within instrument and acknowledged to me that they signed the same in their authorized capacity, and that by their signatures executed this instrument. I certify under PENALTY OF PERJURY under the laws of the State of Arizona that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: ______________________________ (Seal) LW&T Page 14 (of 14) 
  • 17. PDF/17 LOCATER/IDENTIFIER REFERENCE LEDGER JOHN W. DOE Listed below are names, w/relationships (to Testator), addresses and phone numbers of individuals who are parties of this Last Will & Testament Package including beneficiaries, personal representatives, agents, and/or guardians. Individual Address/Phone _________________________________ _________________________________ Name/Relationship _________________________________ _________________________________ _________________________________ _________________________________ Name/Relationship _________________________________ _________________________________ _________________________________ _________________________________ Name/Relationship _________________________________ _________________________________ _________________________________ _________________________________ Name/Relationship _________________________________ _________________________________ _________________________________ _________________________________ Name/Relationship _________________________________ _________________________________ _________________________________ _________________________________ Name/Relationship _________________________________ _________________________________
  • 18. PDF/18 LOCATER/IDENTIFIER REFERENCE LEDGER JOHN W. DOE Listed below are names, w/relationships (to Testator), addresses and phone numbers of individuals who are parties of this Last Will & Testament Package including beneficiaries, personal representatives, agents, and/or guardians. Individual Address/Phone _________________________________ _________________________________ Name/Relationship _________________________________ _________________________________ _________________________________ _________________________________ Name/Relationship _________________________________ _________________________________ _________________________________ _________________________________ Name/Relationship _________________________________ _________________________________ _________________________________ _________________________________ Name/Relationship _________________________________ _________________________________ _________________________________ _________________________________ Name/Relationship _________________________________ _________________________________ _________________________________ _________________________________ Name/Relationship _________________________________ _________________________________
  • 19. PDF/19 LAST WILL AND TESTAMENT JANE E. DOE I, JANE E. DOE, a resident of Maricpoa County, State of Arizona, declare that this is my Last Will and Testament. I hereby revoke all my previous Wills and codicils. ARTICLE I – Introductory Provisions – Marital Status. 1.1. I am married to JOHN W. DOE and all references in this Will to my spouse are to JOHN W. DOE. Identification of Living Children. 1.2. The name(s) of the primary beneficiary(s) of my Will who shall receive of my probate estate – if my spouse does not survive me – accordingly as such dispositive terms are prescribed in Sections 3.4/3.5 (below) is/are: JAMES G. DOE & JOYCE L. DOE Children Defined. 1.3. All references to “child” or “children” are to the child or children as may be listed in Section 1.2 (above), and including any child or children subsequently born to or legally adopted by me after the date of this Will. ARTICLE II – Personal Property Allocations – Tangible Personal Property. 2.1. I give all of my tangible personal property, including my interest in any insurance on that property (if any), to my spouse; however, if my spouse does not survive me and there are no entries on such Personal Property Allocations page, then my personal property shall be distributed as provided in Sections 3.4 – 3.8 (infra) of this Will. LW&T Page 1 (of 14)
  • 20. PDF/20 2.2. If my spouse does not survive me and the beneficiaries of my Will are not able to agree on the division and distribution of my tangible personal property and there are no entries in the Personal Property Allocations page, in such case, then my Executor shall divide and allocate the property as the Executor believes to be in accordance with my wishes. The decision(s) of the Executor thereof shall be deemed valid, complete and final. Specific Gifts. 2.3. Notwithstanding Section 2.1 and 2.2 (above), if I have made any handwritten entries on the Directive of Specific Personal Property Allocations (Page 11 of 13) with my signature thereon, then the specific allocations of such Directive shall apply concerning specific gifts of my personal property. ARTICLE III – Balance of My Probate Estate – Disposition of My Probate Estate if My Spouse Survives Me. 3.1. I give the residue of my entire estate to my spouse, JOHN W. DOE. Disposition Eligibility for Marital Deduction. 3.2. I intend that the disposition in the preceding section be eligible for the federal estate tax marital deduction, and that this instrument shall be construed accordingly. No fiduciary under this Will shall take any action or exercise any power that may impair the federal estate tax marital deduction. If My Spouse Does Not Survive Me or Disclaims. 3.3. If my spouse does not survive me – or shall disclaim all or any part prescribed to my spouse herein where any such disclaimed interest shall be part (or all) of the residue of my probate estate – then I give the residue of my probate estate pursuant to Sections 3.4 – 3.9, as follows: (See Section 3.4/3.5 Estate Allocation Terms on Following Page) LW&T Page 2 (of 14)
  • 21. PDF/21 Division of My Probate Estate if My Spouse Does Not Survive Me. 3.4. IF MY SPOUSE DOES NOT SURVIVE ME, my Executor shall divide my probate estate into as many portions of equal market value as are necessary to create one (1) equal share for each beneficiary named in Section 1.2 (supra). 3.5. My Executor shall then distribute said equal shares outright respectively to each of the beneficiaries identified in Section 1.2, or otherwise according to certain Specific Directives that may be prescribed in Section 3.6 (below). (a) Contingent Distributions. If any beneficiary named in Section 1.2, who is then living at the time of the execution of my Will, does not survive me then such deceased beneficiary's portion shall be distributed EQUALLY TO HIS (HER) SURVIVING LEGAL CHILDREN/ISSUE, BY RIGHT OF REPRESENTATION. And, if any such beneficiary does not survive me and leaves no surviving children/issue, in such case, then that decedent beneficiary's portion shall be distributed equally to the other surviving beneficiaries listed in Section 1.2 (or as otherwise may be prescribed in Section 3.6, below). (b) Notwithstanding the provisions as defined above, sub-paragraph “(e)” (listed below) contains a Schedule of Other/Alternate Primary Beneficiaries which is a list of beneficiaries (if any) and the percentages of my probate estate that each respective beneficiary listed therein shall receive prior to the allocations and distributions prescribed in Sections 1.2 & 3.4/3.5. (c) In such case of the usage of the Schedule of Other/Alternate Primary Beneficiaries, the allocations in Sections 1.2 & 3.4/3.5 shall be deemed to be allocations of the remainder of my probate estate remaining after the allocations/distributions prescribed in sub-paragraphs “(d)” & “(e)” (and/or under Section “3.6” / by Special Directives, if applicable) or shall be deemed as the "Alternate Distribution Schedule” concerning my Will if the beneficiaries listed thereof are to receive all – that is, a one hundred percent (100%) aggregate – of my probate estate. LW&T Page 2 (of 13)
  • 22. PDF/22 (d) If any beneficiary listed in sub-paragraph (e) does not survive me then such decedent person’s designated portion shall be allocated to those other beneficiaries listed there in prorata portions of the aggregate percentage of my probate estate allocated below – unless other provided in Section 3.6 (below): (e) Schedule of Other / Alternate Primary Beneficiaries: _________________________________ / _______% Beneficiary Name _________________________________ / _______% Beneficiary Name _________________________________ / _______% Beneficiary Name _________________________________ / _______% Beneficiary Name _________________________________ / _______% Beneficiary Name _________________________________ / _______% Beneficiary Name _________________________________ / _______% Beneficiary Name (f) Notwithstanding the above, in the event that any beneficiary of my probate estate is then a debtor to me – verified by a written instrument of debt – at the time of my decease then the following shall apply: (i) the share of such indebted beneficiary shall be decreased by a certain formula amount that is equal to the total outstanding value of debt(s) such person owed me, which amount is then (ii) multiplied by a percentage that corresponds to the value of my probate estate (including the value of the debt[s] owed to me) – that such indebted person is not entitled to receive which shall be referred to as the percentage amount; wherein, (iii) such formulated percentage amount shall be subtracted from such indebted person’s share and added prorata to the portion(s) distributable to the other beneficiary(s) of my probate estate who are then living. (g) The following identified person(s) has/have been intentionally disinherited and is/are not to receive any portion(s) of my Will: _______________________________________________________________ _______________________________________________________________ LW&T Page 4 (of 14)
  • 23. PDF/23 Alternate and/or Additional Specific Directives of This Will. NOTICE: Use space below to enter other terms/directives that you want mandated through your Will including but not limited to allocations, if any, to (other) beneficiaries for distributions of "in cash" and/or "in kind": 3.6. The following terms shall ADDITIONALLY apply as to or in place of the administrative and/or allocation terms and/or decrees of my Will notwithstanding any provisions otherwise prescribed anywhere herein to the contrary. Any allocations to beneficiaries prescribed below – whether in cash and/or in kind and/or in unequal percentage amounts – shall be deemed and administrated as part of the Schedule of Other/Alternate Primary Beneficiaries with respect to the terms of allocation/administration prescribed above: _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ < < < End of Section 3.5 > > > Beneficiary Under Age 21. 3.7. If a beneficiary of this Will is under twenty-one (21) years of age, or otherwise deemed as dependent, then my Executor shall establish a “trust” for such beneficiary and pay to or apply for the benefit of such beneficiary, in Executor’s discretion, as much of the income of that beneficiary’s said trust as deemed necessary for his/her health, support, maintenance and education. If my Executor deems the income to be insufficient, he/she may also pay to or apply for the benefit of such beneficiary as much of the principal of beneficiary’s trust as my Executor, in his/her unhindered discretion, deems necessary for the beneficiary’s health, support, maintenance and education. My Executor, in lieu of making direct payments to the beneficiary, may make payments to the beneficiary’s conservator or guardian, to the beneficiary’s custodian under the Uniform Gifts to Minors Act or Uniform Transfers to Minors Act of any state, to one or more suitable persons as my Executor deems proper, or to accounts in the beneficiary’s name with financial institutions. LW&T Page 5 (of 14)
  • 24. PDF/24 Beneficiary Over Age 21. 3.8. If beneficiary of this Will is twenty-one (21) years of age or older, then my Executor shall distribute the balance of the net income and principal of that beneficiary’s allocated trust/portion(s) outright to him/her as soon as administratively possible. Notwithstanding, my Executor may arbitrarily hold any such beneficiary's portion IN TRUST for a later outright distribution period if such action is deemed prudent as it would pertain to that beneficiary's best interest in consideration of all then existing circumstances, and would therefore administer any such beneficiary's portion for his/her benefit per those terms prescribed in Sections 3.4/3.5/3.6 (above). Final Distribution. 3.9. If, under the foregoing provisions, a portion of my estate shall be undisposed of, then such non-disposed portion shall be distributed to my legal heirs whose identity(s) and respective share(s) shall be determined as though my death had occurred immediately following the happening of the event requiring distribution of such undisposed portion of my estate, and according to the laws of succession then in force in the State of Arizona. ARTICLE IV – Nominated Executor – Nomination of Executor. 4.1. I nominate my spouse, JOHN W. DOE, as the Executor of my Will. Successor Executors. 4.2. If my spouse is unable or unwilling to serve or continue as Executor of my Will, then I nominate JAMES G. DOE to serve as my Executor. If JAMES G. DOE is unable or unwilling to serve or continue as the Executor of my Will, in such case, then I nominate JOYCE L. DOE to serve. Waiver of Bond. 4.3. No bond or undertaking shall be required of any Executor nominated herein. LW&T Page 6 (of 14)
  • 25. PDF/25 General Powers of My Executor. 4.4. I authorize but do not direct my Executor to sell any property belonging to my estate, either with or without notice. My Executor is further authorized to invest and reinvest any surplus money, in any kind of property, real, personal, or mixed, and every kind of investment, specifically including, but not limited to, interest-bearing accounts, corporate obligations of every kind, preferred or common stocks, shares of investment trusts, investment companies, mutual funds, or common trust funds, including funds administered by the Executor, and mortgage participations, that persons of prudence, discretion and intelligence acquire for their own account, and to either continue the operation of any business belonging to my estate for such time and in such manner as it may deem advisable and for the best interest of my estate, or to sell or liquidate said business at such time and upon such terms as my Executor may deem advisable and for the best interest of my estate; and any such operation, sale or liquidation shall be at the risk of my estate and without liability on the part of my Executor for any losses resulting therefrom. Independent Administration Permitted. 4.5. My Executor shall have all powers now or hereafter conferred on Executors by law then in force in the State of Arizona except as otherwise specifically provided in this Will, including any powers enumerated in this Will. Division or Distribution in Cash or Kind. 4.6. In order to satisfy a pecuniary gift or to distribute or divide assets into shares or partial shares, the Executor may distribute or divide those assets in kind, or divide undivided interests in those assets, or sell all or any part of those assets and distribute or divide the property in cash, in kind, or partly in cash and partly in kind. Property distributed to satisfy a pecuniary gift under this instrument shall be valued at its fair market value at the time of distribution. Power to Make Tax Elections. 4.7. To the extent permitted by law, and without regard to the resulting effect on any other provision of this Will, on any person interested on the amount of taxes that may be payable, my Executor shall have the power to elect an alternative valuation date for estate tax purposes; choose the methods to pay any death taxes; elect to treat or use any item for state or federal estate or income tax purposes as an income tax deduction or an estate tax deduction; disclaim all or any portion of any interest in property passing to my estate at or after my death; and determine when an item is to be treated as taken into income or used as a tax deduction. LW&T Page 7 (of 14)
  • 26. PDF/26 ARTICLE V – Nominated Guardian – Nomination of Guardian and Successor. (Not Applicable to this Will) Waiver of Bond. 5.2. No bond or undertaking shall be required of any guardian as nominated (per Section 5.1) in this Will. Powers of Guardian(s). 5.3. It is my intent that any guardian nominated in this Will shall have the same authority with respect to the person of the ward as a parent having legal custody of a child would have. It is my intent that all powers granted to guardians named herein may be exercised without unnecessary court authorization. ARTICLE VI – Concluding Provisions – Debts, Taxes and Expenses. 6.1. All of my funeral, last illness, administration expenses and death taxes, shall be paid out of the residue of my estate, subject, however, to the provisions below. Payment of Debt. 6.2. Except for any indebtedness that I may have to any qualified pension, profit sharing or similar plan (other than loans against a voluntary contribution account), which indebtedness shall be promptly paid following my death, the provisions of this Will shall not operate to accelerate any liability; and all indebtedness of mine for which any properties or insurance policies stand as collateral security shall remain an encumbrance upon the same, which shall pass subject to such indebtedness without reimbursement of any kind from my estate. LW&T Page 8 (of 14)
  • 27. PDF/27 Payment of Death Taxes. 6.3. The Executor shall pay death taxes, whether or not attributable to property inventoried in my probate estate, by prorating and apportioning them among the persons having an interest in my estate according to the apportionment provisions as described under Section 2207 of the Internal Revenue Code. Definition of Death Taxes. 6.4. The term “death taxes” as used in this Will, shall mean all inheritance, estate, succession, and other similar taxes that are payable by any person on account of that person’s interest in my estate or by reason of my death, including penalties and interest, but excluding the following: (a) Any (other) additional tax – not described above – that may be assessed in my estate shall be paid by those trusts and/or beneficiaries who receive the assets upon which the additional tax is assessed. (b) Any federal or state tax imposed on a generation-skipping transfer, as that term is defined in the federal tax laws, shall be paid by those trusts and/or beneficiaries who receive the assets upon which the additional tax is assessed. Simultaneous Death. 6.5. If any beneficiary under this Will and I die simultaneously, or if it cannot be established by clear and convincing evidence whether that beneficiary or I died first, I shall be deemed to have survived that beneficiary, and this Will shall be construed accordingly. Period of Survivorship. 6.6. For the purposes of this Will, a beneficiary shall not be deemed to have survived me if that beneficiary dies within thirty (30) days after my death. No-Contest Clause. 6.7. If any heir, devisee, legatee or beneficiary under this Will, or any of my heirs or any person claiming under this Will, my estate, or any trust established by me, whether directly or indirectly, singly or in conjunction with any other person commits any of the actions listed in this Section (et seq.), then all legacies, bequests, devises and interests given under this Will to that person shall be forfeited as though he or she predeceased me without surviving issue: LW&T Page 9 (of 14)
  • 28. PDF/28 (a) Contests or otherwise objects in any court to the validity of this Will, or any share or subtrust created by this Will, or any beneficiary designation account signed by me; (b) Files suit on a creditor’s claim filed in a probate of my estate, or a creditor’s claim on any other document, after rejection or lack of action by the respective fiduciary; (c) Claims ownership to any asset held in joint tenancy by me, other than as a surviving joint tenant; (d) Files a petition for family allowance in a probate of my estate; or brings, joins or is a party to a petition for settlement or for compromise affecting the terms of this instrument; (e) Object in any manner to any action taken or proposed to be taken in good faith by the Executor of my estate or the Executor of any of my trusts (including, without limitation, the good faith exercise or non-exercise of a discretion granted to the Executor or Executor), whether said Executor or Executor is acting under court order, notice of proposed action or otherwise; or, (f) Successfully or unsuccessfully attacks or seeks to impair or invalidate any of the following: any designation of beneficiaries for any insurance policy on my life; any trust which I have created during my lifetime; or any gift which I have made during my lifetime. Expenses. 6.8. Expenses to resist any contest or other attack of any nature upon my estate shall be paid from my estate as expenses of administration. Severable. 6.9. In the event that any provision of this Will is held to be invalid, void or illegal, the same shall be deemed severable from the remainder of the provisions of this Will, and shall in no way affect, impair or invalidate any other provision in this Will. If such provision shall be deemed invalid due to its scope and breadth as described in this Will, such provision shall be deemed valid to the extent of the scope or breadth permitted by law. LW&T Page 10 (of 14)
  • 29. PDF/29 Perpetuities Savings Clause. 6.10. Notwithstanding any other provision of this Will, unless otherwise allowed by applicable state law, every trust created by this Will shall terminate no later than twenty-one (21) years after the death of the last survivor of my issue and the beneficiaries of this Will who are alive at my death. If a trust is terminated under this section of the Will, the Executor shall distribute all of the principal and undistributed income of the trust to the income beneficiaries of that trust in proportion to which they are entitled (or eligible, in the case of discretionary payments) to receive immediately before the termination. If that proportion is not fixed by the terms of this Will, the Executor shall distribute all of the trust property to the persons then entitled or eligible to receive income from the trust outright in a manner that, in the Executor’s opinion, shall give effect to my intent in creating the trust(s). The Executor’s decision is to be final and incontestable by anyone. Severability Clause. 6.11. In the event that any provision of this Will is held to be invalid, void or illegal, the same shall be deemed severable from the remainder of the provisions of this Will and shall in no way affect, impair or invalidate any other provision in this Will. If such provision shall be deemed invalid due to its scope and breadth, such provision shall be deemed valid to the extent of the scope or breadth permitted by law. Arizona Law to Apply. 6.12. All questions concerning the validity and interpretation of this Will, including any trusts created by this Will, shall be governed by the laws of the State of Arizona in effect at the time this Will is executed. ARTICLE VII – Contents, Testimonial and Attestation Provisions – Signature and Attestation. This Last Will & Testament consists of seven (7) Articles – this Article inclusive – and thirteen (13) pages. Following this (final) Article Seven, Testator’s signature, and the witnesses’ attestations hereof is a self-proving affidavit identified on and listed as Page 14. LW&T Page 11 (of 14)
  • 30. PDF/30 Directive of Specific Personal Property Allocations I, JANE E. DOE, in accordance with Section 2.3, of Article II, in my Last Will & Testament, hereby bequeath certain tangible personal property of mine to the persons identified below respective of each separate item adjacent to the person’s name. All such entries on this page may only be handwritten in by me. Personal Property Item Recipient _________________________________ ______________________________ _________________________________ ______________________________ _________________________________ ______________________________ _________________________________ ______________________________ _________________________________ ______________________________ _________________________________ ______________________________ _________________________________ ______________________________ _________________________________ ______________________________ _________________________________ ______________________________ x______________________________ JANE E. DOE LW&T Page 12 (of 14)
  • 31. PDF/31 IN WITNESS WHEREOF, I HAVE HEREUNTO SET MY HAND ON THIS _______ DAY OF ___________________, 2013. x________________________________ JANE E. DOE Signed, sealed, published and declared by the above named Testator as (and for) her Last Will & Testament in our presence who, at her request, in her presence and in the presence of each other, we have hereunto subscribed our names as witnesses. x________________________________ _________________________________ Witness Address x________________________________ _________________________________ Witness Address STATE OF ARIZONA COUNTY OF MARICPOA On this _______ day of _________________, 2013, before me, _____________________, the undersigned Notary Public, personally appeared JANE E. DOE, and the above identified witnesses, who proved to me on the basis of satisfactory evidence to be the persons whose names are subscribed to the within instrument and acknowledged to me that they signed the same in their authorized capacity, and that by their signatures executed this instrument. I certify under PENALTY OF PERJURY under the laws of the State of Arizona that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: ______________________________ (Seal) LW&T Page 13 (of 14) 
  • 32. PDF/32 SELF PROVING AFFIDAVIT STATE OF ARIZONA COUNTY OF MARICPOA I, JANE E. DOE, the Testator of the within, hereby certify that I executed my signature on said Will this ________ day of ___________________, 2013. I further certify that I requested signatures as witnesses to my Last Will & Testament from the following individuals: _______________________________ (and) _______________________________ Witness Name Witness Name x_______________________________ JANE E. DOE We, __________________________ & _________________________, (the witnesses), being first duly sworn, do depose and say to the undersigned authority that we witnessed the Testator's execution of her Will and that she signed it willingly and that each of us, in the presence and hearing of the Testator, hereby sign herein as witness to her signing, and that to the best of our knowledge she is eighteen years of age or older, of sound mind, under no constraint or undue influence and competent to make testamentary disposition of real and personal property. x________________________________ _________________________________ Witness Address x________________________________ _________________________________ Witness Address On this _______ day of ________________, 2013, before me, ______________________, the undersigned Notary Public, personally appeared JANE E. DOE, and the above identified witnesses, who proved to me on the basis of satisfactory evidence to be the persons whose names are subscribed to the within instrument and acknowledged to me that they signed the same in their authorized capacity, and that by their signatures executed this instrument. I certify under PENALTY OF PERJURY under the laws of the State of Arizona that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: ______________________________ (Seal) LW&T Page 14 (of 14) 
  • 33. PDF/33 LOCATER/IDENTIFIER REFERENCE LEDGER JANE E. DOE Listed below are names, w/relationships (to Testatrix), addresses and phone numbers of individuals who are parties of this Last Will & Testament Package including beneficiaries, personal representatives, agents, and/or guardians. Individual Address/Phone _________________________________ _________________________________ Name/Relationship _________________________________ _________________________________ _________________________________ _________________________________ Name/Relationship _________________________________ _________________________________ _________________________________ _________________________________ Name/Relationship _________________________________ _________________________________ _________________________________ _________________________________ Name/Relationship _________________________________ _________________________________ _________________________________ _________________________________ Name/Relationship _________________________________ _________________________________ _________________________________ _________________________________ Name/Relationship _________________________________ _________________________________
  • 34. PDF/34 LOCATER/IDENTIFIER REFERENCE LEDGER JANE E. DOE Listed below are names, w/relationships (to Testatrix), addresses and phone numbers of individuals who are parties of this Last Will & Testament Package including beneficiaries, personal representatives, agents, and/or guardians. Individual Address/Phone _________________________________ _________________________________ Name/Relationship _________________________________ _________________________________ _________________________________ _________________________________ Name/Relationship _________________________________ _________________________________ _________________________________ _________________________________ Name/Relationship _________________________________ _________________________________ _________________________________ _________________________________ Name/Relationship _________________________________ _________________________________ _________________________________ _________________________________ Name/Relationship _________________________________ _________________________________ _________________________________ _________________________________ Name/Relationship _________________________________ _________________________________
  • 35. PDF/35 NOTICE: THE POWERS GRANTED TO THE AGENT YOU ARE APPOINTING HEREIN CAN BE VERY BROAD. CONSULTATION WITH A LEGAL ADVISOR IS RECOMMENDED. THIS DOCUMENT DOES NOT AUTHORIZE THE AGENT NAMED WITHIN TO MAKE MEDICAL OR OTHER HEALTH-CARE DECISIONS FOR YOU. YOU MAY REVOKE THIS POWER OF ATTORNEY AT ANY TIME. DURABLE POWER OF ATTORNEY – OVER ASSETS – This Power of Attorney authorizes the person named below as my Attorney-in-Fact to sell, lease, grant, encumber, release or otherwise convey any interest in my real property, execute deeds and all other such instruments on my behalf unless I have otherwise limited such power herein to specific real property or otherwise withheld such power regarding all real estate transactions as defined below. I, JOHN W. DOE, the undersigned, have appointed JANE E. DOE, my spouse, to serve as my lawful Attorney-in-Fact over assets – or if my spouse is unwilling or unable to serve then I appoint JAMES G. DOE (as my first alternate) or JOYCE L. DOE (as my second alternate) – to perform for me and in my name certain acts which I might and could do if I were present and capable by granting herewith the following INITIALED powers: NOTICE: TO GRANT ALL OF THE FOLLOWING POWERS TO YOUR ATTORNEY-IN-FACT, INITIAL THE LINE IN FRONT OF - (O) - AND IGNORE THE LINES IN FRONT OF ALL THE OTHER LISTED POWERS. NOTICE: TO GRANT ONE OR MORE, BUT FEWER THAN ALL OF THE FOLLOWING POWERS, INITIAL THE LINE IN FRONT OF EACH POWER YOU ARE GRANTING TO YOUR ATTORNEY-IN-FACT. NOTICE: TO WITHHOLD A FOLLOWING POWER(S), DO NOT INITIAL THE LINE ADJACENT TO SUCH POWER. YOU MAY, BUT NEED NOT, CROSS OUT EACH POWER TO BE WITHHELD. AUTHORIZATION BY INITIALS OF UNDERSIGNED PRINCIPAL: _______ (A) To engage in banking and/or other financial institution transactions viz: executing, endorsing, collecting, depositing and receiving checks against or in my bank (or other) accounts, including checks drawn on the Treasurer of the United States. _______ (B) To buy, sell and/or otherwise transfer and/or gift my real estate property or engage in any related real property transactions. _______ (C) to buy, sell and/or otherwise transfer and/or gift my tangible personal property or engage in any related personal property transactions. DPA/Asset Page 1 (of 4)
  • 36. PDF/36 _______ (D) To buy, sell and/or otherwise transfer and/or gift my cash, cash equivalents or other equitable items. _______ (E) To engage in stock and/or bond (including stock or bond powers) transactions. _______ (F) To engage in commodities and/or options transactions. _______ (G) To engage in operational business transactions. _______ (H) To engage in insurance and/or annuity transactions. _______ (I) To engage in personal claims and/or litigation transactions. _______ (J) To engage in personal and/or family maintenance transactions. _______ (K) To receive benefits from social security, Medicare, Medicaid, or other governmental programs, including military service related benefits. _______ (L) To receive or otherwise handle retirement plan(s) transactions. _______ (M) To enter in to my safe deposit box and remove the contents thereof. _______ (N) To handle personal (or related) tax matters. _______ (O) ALL OF THE POWERS LISTED ABOVE. _______ (P) TO RECEIVE REASONABLE FEES/REIMBURSEMENT FOR COSTS & EXPENSES INCURRED AS AN AGENT ACTING HEREUNDER. NOTICE: IF THIS DOCUMENT HAS BEEN ELECTRONICALLY VERIFIED ("ESIGN/ED") THEN ALL OF THE ABOVE ITEMS (A-P) SHALL BE DEEMED AS AFFIRMATIVELY CHECKED/INITIALED. 1. Additionally, I give power to my Attorney-in-Fact to assign, transfer, convey and deliver to the trustee of any trust wherein I maintained a general power of appointment over such trust any and all of my property such as cash, stocks, bonds, securities, annuities and any other property of any kind whether real property or personal; to endorse and deliver to said trustee(s) any checks, drafts, certificates of deposit, notes receivable or other instruments for which I have an interest in as monies payable or belonging to me; to designate the Trustee, of said Trust, as the beneficiary any life insurance policies, employee benefit or pension plans or individual retirement accounts owned by me or in which I have an interest, and, in general, to do all things which I, as a grantor of a living trust, might do if present and capable. 2. Notwithstanding the above provisions, my Attorney-in-Fact shall have NO power to transact with any assets/properties which have been transferred to said Trust either by me or by my Attorney-in-Fact unless the Trustee of said Trust expressly grants to my Attorney-in-Fact the right to act as a nominee Trustee or agent over any specific asset(s) held in said Trust. DPA/Asset Page 2 (of 4)
  • 37. PDF/37 3. Unless otherwise provided hereunder, this Power of Attorney shall spring into effect upon the execution of an opinion letter or medical certification of my attending physician (delivered to my Attorney-in-Fact) certifying my incapacity to carry on my normal fiduciary affairs because of a mental or physical impairment and shall continue therein until a certification from a licensed physician declares that the impairment is no longer effective or applicable. This Power of Attorney shall not be affected by the subsequent disability or incompetence of the principal. Notwithstanding the terms of this paragraph, to the extent this Power of Attorney is intended to be exercised in a jurisdiction not then currently recognizing its efficacy at a "future date" – based upon the occurrence of a future event or contingency – then this Power of Attorney shall be deemed as being effective immediately as to its application in any such jurisdiction. ___________________ I understand the full importance of this Durable Power Of Attorney Over Assets document and I have emotional and mental capacity to execute such document. x________________________________ JOHN W. DOE ACKNOWLEDGEMENT The Declarant signing this foregoing Power of Attorney for Over Assets is personally known to us or has provided proof of his identity, signed or acknowledged his signature on this document in our presence, appears to be of sound mind and not under duress, fraud or undue influence, has not appointed either of us as his health care representative, has not named either of us as a beneficiary of his estate, and is not a patient for whom either of us is an attending physician. x________________________________ _________________________________ Witness Address x________________________________ _________________________________ Witness Address DPA/Asset Page 3 (of 4) 
  • 38. PDF/38 STATE OF ARIZONA COUNTY OF MARICPOA On this ______ day of ________________, 2013, before me, _____________________, the undersigned, personally appeared JOHN W. DOE who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within Durable Power of Attorney Over Assets instrument and acknowledged to me that he executed the same in his authorized capacity, and that by his signature executed this instrument and – _________________________________ & _________________________________ who witnessed the Declarant's signature to this instrument and that to the best of their knowledge the Declarant was at the time eighteen (18) or more years of age, of sound mind and under no constraint or undue influence. I certify under PENALTY OF PERJURY under the laws of the State of Arizona that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: ___________________________ (Seal) DPA/Asset Page 4 (of 4) 
  • 39. PDF/39 NOTICE: THE POWERS GRANTED TO THE AGENT YOU ARE APPOINTING HEREIN CAN BE VERY BROAD. CONSULTATION WITH A LEGAL ADVISOR IS RECOMMENDED. THIS DOCUMENT DOES NOT AUTHORIZE THE AGENT NAMED WITHIN TO MAKE MEDICAL OR OTHER HEALTH-CARE DECISIONS FOR YOU. YOU MAY REVOKE THIS POWER OF ATTORNEY AT ANY TIME. DURABLE POWER OF ATTORNEY ~ OVER ASSETS ~ This Power of Attorney authorizes the person named below as my Attorney-in- Fact to sell, lease, grant, encumber, release or otherwise convey any interest in my real property, execute deeds and all other such instruments on my behalf unless I have otherwise limited such power herein to specific real property or withheld such power regarding all real estate transactions as defined below. I, JANE E. DOE, the undersigned, have appointed JOHN W. DOE, my spouse, to serve as my lawful Attorney-in-Fact over assets – or if my spouse is unwilling or unable to serve then I appoint JAMES G. DOE (as my first alternate) or JOYCE L. DOE (as my second alternate) – to perform for me and in my name certain acts which I might and could do if I were present and capable by granting herewith the following INITIALED powers: NOTICE: TO GRANT ALL OF THE FOLLOWING POWERS TO YOUR ATTORNEY-IN-FACT, INITIAL THE LINE IN FRONT OF - (O) - AND IGNORE THE LINES IN FRONT OF ALL THE OTHER LISTED POWERS. NOTICE: TO GRANT ONE OR MORE, BUT FEWER THAN ALL OF THE FOLLOWING POWERS, INITIAL THE LINE IN FRONT OF EACH POWER YOU ARE GRANTING TO YOUR ATTORNEY-IN-FACT. NOTICE: TO WITHHOLD A FOLLOWING POWER(S), DO NOT INITIAL THE LINE ADJACENT TO SUCH POWER. YOU MAY, BUT NEED NOT, CROSS OUT EACH POWER TO BE WITHHELD. AUTHORIZATION BY INITIALS OF UNDERSIGNED PRINCIPAL: _______ (A) To engage in banking and/or other financial institution transactions viz: executing, endorsing, collecting, depositing and receiving checks against or in my bank (or other) accounts, including checks drawn on the Treasurer of the United States. _______ (B) To buy, sell and/or otherwise transfer and/or gift my real estate property or engage in any related real property transactions. _______ (C) to buy, sell and/or otherwise transfer and/or gift my tangible personal property or engage in any related personal property transactions. DPA/Asset Page 1 (of 4)
  • 40. PDF/40 _______ (D) To buy, sell and/or otherwise transfer and/or gift my cash, cash equivalents or other equitable items. _______ (E) To engage in stock and/or bond (including stock or bond powers) transactions. _______ (F) To engage in commodities and/or options transactions. _______ (G) To engage in operational business transactions. _______ (H) To engage in insurance and/or annuity transactions. _______ (I) To engage in personal claims and/or litigation transactions. _______ (J) To engage in personal and/or family maintenance transactions. _______ (K) To receive benefits from social security, Medicare, Medicaid, or other governmental programs, including military service related benefits. _______ (L) To receive or otherwise handle retirement plan(s) transactions. _______ (M) To enter in to my safe deposit box and remove the contents thereof. _______ (N) To handle personal (or related) tax matters. _______ (O) ALL OF THE POWERS LISTED ABOVE. _______ (P) TO RECEIVE REASONABLE FEES/REIMBURSEMENT FOR COSTS & EXPENSES INCURRED AS AN AGENT ACTING HEREUNDER. NOTICE: IF THIS DOCUMENT HAS BEEN ELECTRONICALLY VERIFIED ("ESIGN/ED") THEN ALL OF THE ABOVE ITEMS (A-P) SHALL BE DEEMED AS AFFIRMATIVELY CHECKED/INITIALED. 1. Additionally, I give power to my Attorney-in-Fact to assign, transfer, convey and deliver to the trustee of any trust wherein I maintained a general power of appointment over such trust any and all of my property such as cash, stocks, bonds, securities, annuities and any other property of any kind whether real property or personal; to endorse and deliver to said trustee(s) any checks, drafts, certificates of deposit, notes receivable or other instruments for which I have an interest in as monies payable or belonging to me; to designate the Trustee, of said Trust, as the beneficiary any life insurance policies, employee benefit or pension plans or individual retirement accounts owned by me or in which I have an interest, and, in general, to do all things which I, as a grantor of a living trust, might do if present and capable. 2. Notwithstanding the above provisions, my Attorney-in-Fact shall have NO power to transact with assets/properties which have been transferred to said Trust either by me or by my Attorney-in-Fact unless the Trustee of said Trust expressly grants to my Attorney-in-Fact the right to act as a nominee Trustee or agent over any specific asset(s) held in said Trust. DPA/Asset Page 2 (of 4)
  • 41. PDF/41 3. Unless otherwise provided hereunder, this Power of Attorney shall spring into effect upon the execution of an opinion letter or medical certification of my attending physician (delivered to my Attorney-in-Fact) certifying my incapacity to carry on my normal fiduciary affairs because of a mental or physical impairment and shall continue therein until a certification from a licensed physician declares that the impairment is no longer effective or applicable. This Power of Attorney shall not be affected by the subsequent disability or incompetence of the principal. Notwithstanding the terms of this paragraph, to the extent this Power of Attorney is intended to be exercised in a jurisdiction not then currently recognizing its efficacy at a "future date" – based upon the occurrence of a future event or contingency – then this Power of Attorney shall be deemed as being effective immediately as to its application in any such jurisdiction. ________________ I understand the full importance of this Durable Power Of Attorney Over Assets document and I have emotional and mental capacity to execute such document. x________________________________ JANE E. DOE ACKNOWLEDGEMENT The Declarant signing this foregoing Power of Attorney for Over Assets is personally known to us or has provided proof of her identity, signed or acknowledged her signature on this document in our presence, appears to be of sound mind and not under duress, fraud or undue influence, has not appointed either of us as her health care representative, has not named either of us as a beneficiary of her estate, and is not a patient for whom either of us is an attending physician. x________________________________ _________________________________ Witness Address x________________________________ _________________________________ Witness Address DPA/Asset Page 3 (of 4) 
  • 42. PDF/42 STATE OF ARIZONA COUNTY OF MARICPOA On this ______ day of ________________, 2013, before me, _____________________, the undersigned, personally appeared JANE E. DOE who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within Durable Power of Attorney Over Assets instrument and acknowledged to me that she executed the same in her authorized capacity, and that by her signature executed this instrument and – _________________________________ & _________________________________ who witnessed the Declarant's signature to this instrument and that to the best of their knowledge the Declarant was at the time eighteen (18) or more years of age, of sound mind and under no constraint or undue influence. I certify under PENALTY OF PERJURY under the laws of the State of Arizona that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: ___________________________ (Seal) DPA/Asset Page 4 (of 4) 
  • 43. PDF/43 DURABLE AGENT NOTICE TO WHOM IT CONCERNS: I, ________________________________, the undersigned AFFIANT, named as the Durable (Attorney-in-Fact) Agent for JOHN W. DOE, the principal, in that certain Durable Power of Attorney Over Assets document dated - the ______ day of ________________, ________: (Applicable statement checked by affiant) _____ Have accepted such appointment and shall act according to the power and authority granted to me as the durable attorney-in-fact for such named principal; further, I attest that the above named principal is (i) still alive, (ii) was competent at the time of the execution of said Power of Attorney and that (iii) such Power of Attorney remains valid and in full effect. _____ Have not accepted such appointment and shall decline forever my appointment as the durable attorney-in-fact for such named principal. _____ Have by succession, according to an appropriate document (concerning the first appointee) of (ii) Declination Certificate or (ii) Medical Certificate, attached hereto and made a part hereof, accept such appointment as the durable attorney-in-fact for such named principal. x________________________________ Affiant - ACKNOWLEDGEMENT - STATE OF _______________________ COUNTY OF _____________________ On this ______ day of ______________________, before me, _______________________, the undersigned Notary Public, personally appeared _________________________________, (Affiant), who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to this instrument and acknowledged to me that he/she executed/signed the same in his/her authorized capacity, and that by his/her signature executed/signed this instrument. I certify under PENALTY OF PERJURY under the laws of the State of ___________________ that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: ______________________________ (Seal)
  • 44. PDF/44 DURABLE AGENT NOTICE TO WHOM IT CONCERNS: I, ________________________________, the undersigned AFFIANT, named as the Durable (Attorney-in-Fact) Agent for JANE E. DOE, the principal, in that certain Durable Power of Attorney Over Assets document dated - the ______ day of ________________, ________: (Applicable statement checked by affiant) _____ Have accepted such appointment and shall act according to the power and authority granted to me as the durable attorney-in-fact for such named principal; further, I attest that the above named principal is (i) still alive, (ii) was competent at the time of the execution of said Power of Attorney and that (iii) such Power of Attorney remains valid and in full effect. _____ Have not accepted such appointment and shall decline forever my appointment as the durable attorney-in-fact for such named principal. _____ Have by succession, according to an appropriate document (concerning the first appointee) of (ii) Declination Certificate or (ii) Medical Certificate, attached hereto and made a part hereof, accept such appointment as the durable attorney-in-fact for such named principal. x________________________________ Affiant - ACKNOWLEDGEMENT - STATE OF _______________________ COUNTY OF _____________________ On this ______ day of ______________________, before me, _______________________, the undersigned Notary Public, personally appeared _________________________________, (Affiant), who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to this instrument and acknowledged to me that he/she executed/signed the same in his/her authorized capacity, and that by his/her signature executed/signed this instrument. I certify under PENALTY OF PERJURY under the laws of the State of ___________________ that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: ______________________________ (Seal)
  • 45. PDF/45 DURABLE POWER OF ATTORNEY – FOR HEALTH CARE – I, JOHN W. DOE, a resident of Maricpoa County, State of Arizona, do now declare this to be a Durable Power of Attorney for Health Care declaration for me under the laws of any jurisdiction I may be in at any time of my disability. 1. I hereby appoint JANE E. DOE, my spouse, as my true and lawful Attorney-in-Fact agent for health care. If my spouse is unable or unavailable to serve as my agent then I designate JAMES G. DOE (as my alternate agent) to serve. Otherwise, JOYCE L. DOE shall serve (as my second alternate agent) if my first alternate agent cannot serve, in such case. 2. Unless My ADVANCE HEALTH CARE DIRECTIVE Provides Otherwise For Specific Instructions Regarding Any Actions and/or Terms Prescribed Herein or That Revokes This Instrument Entirely – I hereby authorize my Attorney-in-Fact to perform the following acts if I become incapable of giving informed consent: A) REQUEST, RECEIVE, AND REVIEW ANY INFORMATION, VERBAL OR WRITTEN, REGARDING MY PHYSICAL CONDITION OR MENTAL HEALTH INCLUDING, BUT NOT LIMITED TO, MEDICAL AND HOSPITAL RECORDS AND CONSENT TO DISCLOSURE OF MY MEDICAL RECORDS; B) CONSENT, REFUSE TO CONSENT, OR WITHDRAW CONSENT TO ANY TREATMENT OR CARE TO MAINTAIN, TREAT, OR DIAGNOSE A PHYSICAL OR MENTAL CONDITION; AND, C) CONSENT TO WITHDRAWAL OR WITHHOLDING OF ANY TYPE OF TREATMENT THAT WOULD KEEP ME ALIVE - THIS POWER INCLUDES THE POWER TO WITHDRAW OR WITHHOLD HYDRATION OR FOOD IF I AM COMATOSE AND/OR TERMINALLY ILL. 3. I revoke any prior Durable Power of Attorney for Health Care. This Durable Power of Attorney for Health Care shall take precedence over any power of attorney (general, special, or medical) which I may sign upon my admission to any hospital or other health care facility. This Durable Power of Attorney for Health Care supplements (if necessary) any Living Will Declaration that I have executed. 4. It is my intention, by this instrument, to provide for my personal and medical assistance without the necessity of court action. Accordingly, I request, in the strongest possible terms that any court which may receive or act upon a petition for the appointment of a guardian for me should deny such petition so long as my Attorney-in-Fact is acting as appointed. If any court shall deem it necessary to appoint a guardian in spite of this request, then I request that my Attorney-in-Fact be appointed unless I have provided otherwise. DPA/Health Page 1 (of 4)
  • 46. PDF/46 5. This instrument shall be governed by the laws of the state of my domicile including its construction, interpretation and termination and, to the extent permitted by law, shall be applicable to wherever and in whatever state of the United States or foreign country I may be at the time. 6. If any part of any provision of this instrument shall be invalid or unenforceable under applicable law, such part shall be ineffective to the extent of such invalidity only, without affecting the remaining, valid provisions of this instrument. 7. This instrument may be amended or revoked by me. My Attorney-in-Fact (and any alternate) may be removed by my revocation or amendment by me. If this instrument has been recorded in the public records, then the instrument of revocation, amendment or removal shall be filed or recorded in the same public records. My Attorney-in-Fact may resign by the execution of a written resignation delivered to me, or if I am mentally incapacitated, by delivery to any person with whom I am residing or who has the care and custody of me, or in the case of an alternate, by delivery to my Attorney-in-Fact. 8. My Attorney-in-Fact shall have full power and authority to do so and perform all acts whatsoever requisite to be done in order to fully accomplish the aforementioned to all intents and purposes as I might or could do otherwise. I hereby ratify and confirm all that my Attorney-in-Fact shall do or cause to be done by virtue of this instrument. 9. Every physician, hospital, care provider, or other person, firm or corporation to which this instrument is presented to (or presented a photocopy hereof) is expressly authorized to honor and give effect to all instruments signed pursuant to the foregoing authority without inquiring as to the circumstances of their issuance or the disposition of the property delivered pursuant thereto. 10. For purposes of this instrument, I shall be considered to be disabled if I lack sufficient capacity to make or communicate responsible decisions concerning my welfare by reason of mental illness, mental deficiency, mental disorder, physical illness or disability, chronic use of drugs, chronic intoxication or other cause. This existence of such a disability shall be conclusively established by attaching to this instrument the sworn statement of my attending physician stating that he or she has examined me and believes that the existence of one (or more) of such stated conditions exists to cause my incapacity. 11. The validity of (i) my restoration of my competency or (ii) the declaration of my disability which gave rise to the effectiveness of this Durable Power of Attorney for Health Care may only be revoked by my express written revocation or by the express written revocation of my duly appointed conservator. 12. In the event that this Durable Power of Attorney for Health Care becomes effective by reason of my disability, my revocation shall be accompanied by a sworn statement of a physician stating that he or she (i) has examined me, (ii) believes that the condition giving rise to the effectiveness of this Durable Power of Attorney for Health Care has been removed and (iii) believes that I possess the understanding and capacity to make responsible decisions regarding my welfare. DPA/Health Page 2 (of 4)
  • 47. PDF/47 WARNING TO PERSON EXECUTING THIS DOCUMENT THIS IS AN IMPORTANT LEGAL DOCUMENT. IT CREATES A DURABLE POWER OF ATTORNEY FOR HEALTH CARE. BEFORE EXECUTING THIS DOCUMENT, YOU SHOULD KNOW THESE IMPORTANT FACTS:  THIS DOCUMENT GIVES THE PERSON YOU HAVE DESIGNATED, AS YOUR ATTORNEY-IN-FACT, THE POWER TO MAKE HEALTH CARE DECISIONS FOR YOU, SUBJECT TO ANY LIMITATIONS OR STATEMENT OF YOUR DESIRES THAT YOU INCLUDE IN THIS DOCUMENT. THE POWER TO MAKE HEALTH CARE DECISIONS FOR YOU MAY INCLUDE CONSENT, REFUSAL TO CONSENT, OR WITHDRAWAL OF CONSENT TO ANY CARE, TREATMENT, SERVICE, OR PROCEDURE TO MAINTAIN, DIAGNOSE, OR TREAT A PHYSICAL OR MENTAL CONDITION. YOU MAY STATE IN THIS DOCUMENT ANY TYPES OF TREATMENT OR PLACEMENTS THAT YOU DO NOT DESIRE.  THE PERSON YOU HAVE DESIGNATED IN THIS DOCUMENT HAS A DUTY TO ACT IN ACCORDANCE WITH YOUR DESIRES AS STATED IN THIS DOCUMENT OR OTHERWISE MADE KNOWN. IF YOUR DESIRES ARE UNKNOWN, YOUR ATTORNEY-IN-FACT IS TO ACT IN YOUR BEST INTERESTS.  UNLESS OTHERWISE SPECIFIED IN THIS DOCUMENT, YOUR ATTORNEY-IN- FACT HAS THE POWER TO MAKE HEALTH CARE DECISIONS FOR YOU; THIS MAY INCLUDE CONSENTING TO WITHHOLD TREATMENT WHICH COULD PROLONG YOUR LIFE.  NOTWITHSTANDING THIS DOCUMENT, YOU HAVE THE RIGHT TO MAKE MEDICAL AND OTHER HEALTH CARE DECISIONS FOR YOURSELF AS LONG AS YOU CAN GIVE INFORMED CONSENT WITH RESPECT TO THE PARTICULAR DECISION. IN ADDITION, NO TREATMENT OR ANY HEALTH CARE NECESSARY TO KEEP YOU ALIVE MAY BE ADMINISTERED OVER YOUR OBJECTION.  YOU HAVE THE RIGHT TO REVOKE THE AUTHORITY GRANTED TO THE PERSON DESIGNATED IN THIS DOCUMENT TO MAKE HEALTH CARE DECISIONS FOR YOU BY NOTIFYING THE TREATING PHYSICIAN, HOSPITAL, OR OTHER HEALTH CARE PROVIDER, ORALLY OR IN WRITING.  THE PERSON DESIGNATED IN THIS DOCUMENT TO MAKE HEALTH CARE DECISIONS FOR YOU HAS THE RIGHT TO EXAMINE YOUR MEDICAL RECORDS AND TO CONSENT TO THEIR DISCLOSURE UNLESS YOU LIMIT THIS RIGHT IN THIS DOCUMENT.  IF THERE IS ANYTHING IN THIS DOCUMENT THAT YOU DO NOT UNDERSTAND, YOU SHOULD ASK A LAWYER TO EXPLAIN IT TO YOU.  THIS HEALTH CARE DECLARATION SHOULD BE SIGNED BY TWO ELIGIBLE WITNESSES WHO ARE NEITHER BENEFICIARIES OF YOUR ESTATE NOR RELATED BY BLOOD, MARRIAGE, OR ADOPTION AND PRESENT WHEN YOU SIGN THIS DOCUMENT BEFORE A NOTARY PUBLIC. DPA/Health Page 3 (of 4)
  • 48. PDF/48 I hereby declare that I have executed this Durable Power of Attorney for Health Care on this day, the ______ day of _____________________, 2013, consisting of four (4) pages including the "warning" page (3) and this page. x________________________________ JOHN W. DOE ACKNOWLEDGEMENT The Declarant signing this foregoing Power of Attorney for Health Care is personally known to us or has provided proof of his identity, signed or acknowledged his signature on this document in our presence, appears to be of sound mind and not under duress, fraud or undue influence, has not appointed either of us as his health care representative, has not named either of us as a beneficiary of his estate, and is not a patient for whom either of us is an attending physician. x________________________________ _________________________________ Witness Address x________________________________ _________________________________ Witness Address STATE OF ARIZONA COUNTY OF MARICPOA On this ______ day of ________________, 2013, before me, _____________________, the undersigned, personally appeared JOHN W. DOE who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument and acknowledged to me that he executed the same in his authorized capacity, and that by his signature executed this instrument and – _________________________________ & _________________________________ who witnessed the Declarant's signature to this instrument and that to the best of their knowledge the Declarant was at the time eighteen (18) or more years of age, of sound mind and under no constraint or undue influence. I certify under PENALTY OF PERJURY under the laws of the State of Arizona that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: ___________________________ (Seal) DPA/Health Page 4 (of 4) 
  • 49. PDF/49 DURABLE POWER OF ATTORNEY – FOR HEALTH CARE – I, JANE E. DOE, a resident of Maricpoa County, State of Arizona, do now declare this to be a Durable Power of Attorney for Health Care declaration for me under the laws of any jurisdiction I may be in at any time of my disability. 1. I hereby appoint JOHN W. DOE, my spouse, as my true and lawful Attorney-in-Fact agent for health care. If my spouse is unable or unavailable to serve as my agent then I designate (Not Specified) (as my alternate agent) to serve. 2. Unless My ADVANCE HEALTH CARE DIRECTIVE Provides Otherwise For Specific Instructions Regarding Any Actions and/or Terms Prescribed Herein or That Revokes This Instrument Entirely – I hereby authorize my Attorney-in-Fact to perform the following acts if I become incapable of giving informed consent: A) REQUEST, RECEIVE, AND REVIEW ANY INFORMATION, VERBAL OR WRITTEN, REGARDING MY PHYSICAL CONDITION OR MENTAL HEALTH INCLUDING, BUT NOT LIMITED TO, MEDICAL AND HOSPITAL RECORDS AND CONSENT TO DISCLOSURE OF MY MEDICAL RECORDS; B) CONSENT, REFUSE TO CONSENT, OR WITHDRAW CONSENT TO ANY TREATMENT OR CARE TO MAINTAIN, TREAT, OR DIAGNOSE A PHYSICAL OR MENTAL CONDITION; AND, C) CONSENT TO WITHDRAWAL OR WITHHOLDING OF ANY TYPE OF TREATMENT THAT WOULD KEEP ME ALIVE - THIS POWER INCLUDES THE POWER TO WITHDRAW OR WITHHOLD HYDRATION OR FOOD IF I AM COMATOSE AND/OR TERMINALLY ILL. 3. I revoke any prior Durable Power of Attorney for Health Care. This Durable Power of Attorney for Health Care shall take precedence over any power of attorney (general, special, or medical) which I may sign upon my admission to any hospital or other health care facility. This Durable Power of Attorney for Health Care supplements (if necessary) any Living Will Declaration that I have executed. 4. It is my intention, by this instrument, to provide for my personal and medical assistance without the necessity of court action. Accordingly, I request, in the strongest possible terms that any court which may receive or act upon a petition for the appointment of a guardian for me should deny such petition so long as my Attorney-in-Fact is acting as appointed. If any court shall deem it necessary to appoint a guardian in spite of this request, then I request that my Attorney-in-Fact be appointed unless I have provided otherwise. DPA/Health Page 1 (of 4)
  • 50. PDF/50 5. This instrument shall be governed by the laws of the state of my domicile including its construction, interpretation and termination and, to the extent permitted by law, shall be applicable to wherever and in whatever state of the United States or foreign country I may be at the time. 6. If any part of any provision of this instrument shall be invalid or unenforceable under applicable law, such part shall be ineffective to the extent of such invalidity only, without affecting the remaining, valid provisions of this instrument. 7. This instrument may be amended or revoked by me. My Attorney-in-Fact (and any alternate) may be removed by my revocation or amendment by me. If this instrument has been recorded in the public records, then the instrument of revocation, amendment or removal shall be filed or recorded in the same public records. My Attorney-in-Fact may resign by the execution of a written resignation delivered to me, or if I am mentally incapacitated, by delivery to any person with whom I am residing or who has the care and custody of me, or in the case of an alternate, by delivery to my Attorney-in-Fact. 8. My Attorney-in-Fact shall have full power and authority to do so and perform all acts whatsoever requisite to be done in order to fully accomplish the aforementioned to all intents and purposes as I might or could do otherwise. I hereby ratify and confirm all that my Attorney-in-Fact shall do or cause to be done by virtue of this instrument. 9. Every physician, hospital, care provider, or other person, firm or corporation to which this instrument is presented to (or presented a photocopy hereof) is expressly authorized to honor and give effect to all instruments signed pursuant to the foregoing authority without inquiring as to the circumstances of their issuance or the disposition of the property delivered pursuant thereto. 10. For purposes of this instrument, I shall be considered to be disabled if I lack sufficient capacity to make or communicate responsible decisions concerning my welfare by reason of mental illness, mental deficiency, mental disorder, physical illness or disability, chronic use of drugs, chronic intoxication or other cause. This existence of such a disability shall be conclusively established by attaching to this instrument the sworn statement of my attending physician stating that he or she has examined me and believes that the existence of one (or more) of such stated conditions exists to cause my incapacity. 11. The validity of (i) my restoration of my competency or (ii) the declaration of my disability which gave rise to the effectiveness of this Durable Power of Attorney for Health Care may only be revoked by my express written revocation or by the express written revocation of my duly appointed conservator. 12. In the event that this Durable Power of Attorney for Health Care becomes effective by reason of my disability, my revocation shall be accompanied by a sworn statement of a physician stating that he or she (i) has examined me, (ii) believes that the condition giving rise to the effectiveness of this Durable Power of Attorney for Health Care has been removed and (iii) believes that I possess the understanding and capacity to make responsible decisions regarding my welfare. DPA/Health Page 2 (of 4)
  • 51. PDF/51 WARNING TO PERSON EXECUTING THIS DOCUMENT THIS IS AN IMPORTANT LEGAL DOCUMENT. IT CREATES A DURABLE POWER OF ATTORNEY FOR HEALTH CARE. BEFORE EXECUTING THIS DOCUMENT, YOU SHOULD KNOW THESE IMPORTANT FACTS:  THIS DOCUMENT GIVES THE PERSON YOU HAVE DESIGNATED, AS YOUR ATTORNEY-IN-FACT, THE POWER TO MAKE HEALTH CARE DECISIONS FOR YOU, SUBJECT TO ANY LIMITATIONS OR STATEMENT OF YOUR DESIRES THAT YOU INCLUDE IN THIS DOCUMENT. THE POWER TO MAKE HEALTH CARE DECISIONS FOR YOU MAY INCLUDE CONSENT, REFUSAL TO CONSENT, OR WITHDRAWAL OF CONSENT TO ANY CARE, TREATMENT, SERVICE, OR PROCEDURE TO MAINTAIN, DIAGNOSE, OR TREAT A PHYSICAL OR MENTAL CONDITION. YOU MAY STATE IN THIS DOCUMENT ANY TYPES OF TREATMENT OR PLACEMENTS THAT YOU DO NOT DESIRE.  THE PERSON YOU HAVE DESIGNATED IN THIS DOCUMENT HAS A DUTY TO ACT IN ACCORDANCE WITH YOUR DESIRES AS STATED IN THIS DOCUMENT OR OTHERWISE MADE KNOWN. IF YOUR DESIRES ARE UNKNOWN, YOUR ATTORNEY-IN-FACT IS TO ACT IN YOUR BEST INTERESTS.  UNLESS OTHERWISE SPECIFIED IN THIS DOCUMENT, YOUR ATTORNEY-IN- FACT HAS THE POWER TO MAKE HEALTH CARE DECISIONS FOR YOU; THIS MAY INCLUDE CONSENTING TO WITHHOLD TREATMENT WHICH COULD PROLONG YOUR LIFE.  NOTWITHSTANDING THIS DOCUMENT, YOU HAVE THE RIGHT TO MAKE MEDICAL AND OTHER HEALTH CARE DECISIONS FOR YOURSELF AS LONG AS YOU CAN GIVE INFORMED CONSENT WITH RESPECT TO THE PARTICULAR DECISION. IN ADDITION, NO TREATMENT OR ANY HEALTH CARE NECESSARY TO KEEP YOU ALIVE MAY BE ADMINISTERED OVER YOUR OBJECTION.  YOU HAVE THE RIGHT TO REVOKE THE AUTHORITY GRANTED TO THE PERSON DESIGNATED IN THIS DOCUMENT TO MAKE HEALTH CARE DECISIONS FOR YOU BY NOTIFYING THE TREATING PHYSICIAN, HOSPITAL, OR OTHER HEALTH CARE PROVIDER, ORALLY OR IN WRITING.  THE PERSON DESIGNATED IN THIS DOCUMENT TO MAKE HEALTH CARE DECISIONS FOR YOU HAS THE RIGHT TO EXAMINE YOUR MEDICAL RECORDS AND TO CONSENT TO THEIR DISCLOSURE UNLESS YOU LIMIT THIS RIGHT IN THIS DOCUMENT.  IF THERE IS ANYTHING IN THIS DOCUMENT THAT YOU DO NOT UNDERSTAND, YOU SHOULD ASK A LAWYER TO EXPLAIN IT TO YOU.  THIS HEALTH CARE DECLARATION SHOULD BE SIGNED BY TWO ELIGIBLE WITNESSES WHO ARE NEITHER BENEFICIARIES OF YOUR ESTATE NOR RELATED BY BLOOD, MARRIAGE, OR ADOPTION AND PRESENT WHEN YOU SIGN THIS DOCUMENT BEFORE A NOTARY PUBLIC. DPA/Health Page 3 (of 4)
  • 52. PDF/52 I hereby declare that I have executed this Durable Power of Attorney for Health Care on this day, the ______ day of _____________________, 2013, consisting of four (4) pages including the "warning" page (3) and this page. x________________________________ JANE E. DOE ACKNOWLEDGEMENT The Declarant signing this foregoing Power of Attorney for Health Care is personally known to us or has provided proof of her identity, signed or acknowledged her signature on this document in our presence, appears to be of sound mind and not under duress, fraud or undue influence, has not appointed either of us as her health care representative, has not named either of us as a beneficiary of her estate, and is not a patient for whom either of us is an attending physician. x________________________________ _________________________________ Witness Address x________________________________ _________________________________ Witness Address STATE OF ARIZONA COUNTY OF MARICPOA On this ______ day of ________________, 2013, before me, _____________________, the undersigned, personally appeared JANE E. DOE who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument and acknowledged to me that she executed the same in her authorized capacity, and that by her signature executed this instrument and – _________________________________ & _________________________________ who witnessed the Declarant's signature to this instrument and that to the best of their knowledge the Declarant was at the time eighteen (18) or more years of age, of sound mind and under no constraint or undue influence. I certify under PENALTY OF PERJURY under the laws of the State of Arizona that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: ___________________________ (Seal) DPA/Health Page 4 (of 4) 
  • 53. PDF/53 HEALTH CARE AGENT NOTICE TO WHOM IT CONCERNS: I, ________________________________, the undersigned AFFIANT, named as the Health Care Agent for JOHN W. DOE, the Principal, in that certain - Durable Power of Attorney for Health Care document dated - the ______ day of ________________, ________: declare and state the following: I hereby accept this appointment and agree to serve as agent for the Principal concerning his Health Care decisions in the event that he is incapable in making such decisions himself. I understand that I have a duty to act consistently with the desires of the Principal as expressed in such appointment. I understand that said document gives me authority over health care decisions for him only if he becomes incapable and that I must act in good faith in exercising my authority under such appointment. I acknowledge that the principal, if competent, may revoke said Health Care Power of Attorney at any time and in any manner. If I choose to withdraw during the time the principal is competent, I must notify him of my decision. If I choose to withdraw when the principal is incapable of making his own health care decisions then I must notify his physician. x________________________________ Affiant STATE OF _______________________ COUNTY OF _____________________ On this ______ day of ________________, ________, before me, __________________, the undersigned, personally appeared _________________________________, (Affiant), who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to this instrument and acknowledged to me that he/she executed/signed the same in his/her authorized capacity, and that by his/her signature executed/signed this instrument. I certify under PENALTY OF PERJURY under the laws of the State of ___________________ that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: ______________________________ (Seal)
  • 54. PDF/54 HEALTH CARE AGENT NOTICE TO WHOM IT CONCERNS: I, ________________________________, the undersigned AFFIANT, named as the Health Care Agent for JANE E. DOE, the Principal, in that certain - Durable Power of Attorney for Health Care document dated - the ______ day of ________________, ________: declare and state the following: I hereby accept this appointment and agree to serve as agent for the Principal concerning her Health Care decisions in the event that she is incapable in making such decisions herself. I understand that I have a duty to act consistently with the desires of the Principal as expressed in such appointment. I understand that said document gives me authority over health care decisions for her only if she becomes incapable and that I must act in good faith in exercising my authority under such appointment. I acknowledge that the principal, if competent, may revoke said Health Care Power of Attorney at any time and in any manner. If I choose to withdraw during the time the principal is competent, I must notify her of my decision. If I choose to withdraw when the principal is incapable of making her own health care decisions then I must notify her physician. x________________________________ Affiant STATE OF _______________________ COUNTY OF _____________________ On this ______ day of _______________, ________, before me, ___________________, the undersigned, personally appeared _________________________________, (Affiant), who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to this instrument and acknowledged to me that he/she executed/signed the same in his/her authorized capacity, and that by his/her signature executed/signed this instrument. I certify under PENALTY OF PERJURY under the laws of the State of ___________________ that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: ______________________________ (Seal)
  • 55. PDF/55 PLEASE NOTICE The following document(s) is referred to as an – ADVANCE DIRECTIVE for HEALTH CARE An Advance Directive (for health care) can work with or without a Durable Power of Attorney for Health Care and is generally used in conjunction with a Living Will (as does a Health Care Power of Attorney). However, you do not have to fill out and sign this form. You may sign the Advance Directive now or at a later date or not at all. Whatever choice you make, it is recommended that you review the document at your earliest convenience. It is not the place or the responsibility of a financial or tax advisor to explain matters pertaining to health care documents. If you do not understand any of the components of the Advance Directive or how it works in conjunction with any other health care document(s) that you may have executed, then it is recommended that you seek out a doctor or other medical assistant to explain the issues that are unclear to you. ____________________
  • 56. PDF/56 ADVANCE HEALTH CARE DIRECTIVE PART “A” – IMPORTANT INFORMATION / PLEASE READ This is an important legal document. It can control optional but critical decisions about your health care. Before signing, consider these important facts: 1) YOU HAVE THE RIGHT TO NAME A PERSON TO DIRECT AND CONTROL YOUR HEALTH CARE PREFERENCES – REFERRED TO AS YOUR "HEALTH CARE AGENT" – IN PART "C" OF THIS FORM. YOU MAY APPOINT A PRIMARY PHYSICIAN – TO ADMINISTER YOUR HEALTH CARE DIRECTIVES – IN PART “F” OF THIS FORM. 2) YOU CAN WRITE ANY RESTRICTIONS HEREIN THAT YOU MAY WANT ON HOW YOUR AGENT IS TO MAKE DECISIONS ON YOUR BEHALF. YOUR AGENT MUST FOLLOW YOUR DESIRES AS STATED IN THIS DOCUMENT OR OTHERWISE MADE KNOWN BY YOU. IF YOUR DESIRES ARE UNKNOWN, YOUR AGENT IS TO ACT IN YOUR BEST INTEREST. YOUR AGENT CAN RESIGN AT ANY TIME. 3) UNLESS OTHERWISE INDICATED HEREIN OR IN OTHER DOCUMENTATION, YOUR AGENT WILL HAVE THE RIGHT TO: (A) CONSENT OR REFUSE ANY CARE, TREATMENT, OR PROCEDURE TO MAINTAIN, DIAGNOSE, OR OTHERWISE AFFECT YOUR PHYSICAL OR MENTAL CONDITION; (B) SELECT OR DISCHARGE HEALTH CARE PROVIDERS AND INSTITUTIONS; (C) APPROVE OR DISAPPROVE DIAGNOSTIC TESTS, SURGICAL PROCEDURES, AND PROGRAMS OF MEDICATION; (D) DIRECT THE PROVISION, WITHHOLDING, OR WITHDRAWAL OF ARTIFICIAL NUTRITION AND HYDRATION AND ALL OTHER FORMS OF HEALTH CARE, INCLUDING CARDIOPULMONARY RESUSCITATION; (E) MAKE ANATOMICAL GIFTS, (F) AUTHORIZE AN AUTOPSY, AND (G) DIRECT DISPOSITION OF REMAINS. 4) YOU HAVE THE RIGHT TO GIVE SPECIFIC “CHECK THE BOX” & WRITTEN INSTRUCTIONS FOR HEALTH CARE PROVIDERS TO FOLLOW IF YOU BECOME UNABLE TO DIRECT YOUR OWN CARE - BY USING PART "B" OF THIS FORM. 5) THIS FORM IS VALID ONLY IF YOU SIGN IT VOLUNTARILY AND WHEN YOU ARE OF SOUND MIND. IF YOU DO NOT WANT AN ADVANCE DIRECTIVE HEREIN, YOU DO NOT HAVE TO SIGN THIS FORM. 6) UNLESS YOU HAVE LIMITED THE DURATION OF THIS ADVANCE DIRECTIVE, IT WILL NOT EXPIRE. IF YOU HAVE SET AN EXPIRATION DATE AND YOU BECOME UNABLE TO DIRECT YOUR HEALTH CARE AGENT BEFORE THAT DATE, THIS ADVANCE DIRECTIVE WILL NOT EXPIRE UNTIL YOU ARE ABLE TO MAKE THOSE DECISIONS AGAIN. 7) YOU MAY REVOKE THIS DOCUMENT AT ANY TIME. TO DO SO, NOTIFY YOUR AGENT AND YOUR HEALTH CARE PROVIDER OF THE REVOCATION. NOTWITHSTANDING THIS DOCUMENT, YOU HAVE THE RIGHT TO DECIDE ON YOUR OWN HEALTH CARE AS LONG AS YOU ARE ABLE TO DO SO. 8) YOU MAY CROSS OUT WORDS THAT DON'T EXPRESS YOUR WISHES OR ADD WORDS THAT BETTER EXPRESS YOUR WISHES; INITIAL ALL CHANGES YOU MAKE. FOR THIS DOCUMENT TO BE LEGALLY VALID, YOU MUST SIGN IT UNDER A NOTARY PUBLIC. Adv/Dir Page 1 (of 8)
  • 57. PDF/57 PART “B” – HEALTH CARE DIRECTIVES BY: NAME: JOHN W. DOE ADDRESS: 13 Mockingbird Ln CITYSTZIP: Phoenix, AZ 85001 1) I REVOKE ALL PRIOR Advance Directives signed by me. This document shall remain valid and effective in the event that I become incapacitated. A copy and/or an electronic file of this form shall have the same effect as the original document. 2) Close to Death / End of Life – If I am (a) close to death where tube feeding and/or life support would only postpone the moment of my death, and/or (b) unconscious and it is highly unlikely that I will ever regain consciousness again, and/or (c) I have a progressive illness that will be fatal and is in an advanced stage, and I am consistently and permanently unable to communicate by any means, swallow food and water safely, care for myself and recognize loved ones, and it is very unlikely that my condition will substantially improve, then I request that the following actions be taken (or not taken): Initial as applicable (tube feeding): Initial as applicable (life support): _____ I want tube feeding/hydration _____ I want life support _____ As my Agent recommends _____ As my Agent recommends _____ As my Physician recommends _____ As my Physician recommends _____ I want no tube feeding/hydration _____ I want no life support _____ See my written directives herein _____ See my written directives herein (OR) / Initial as applicable (state your general directives): _____ I CHOOSE NOT TO PROLONG MY LIFE – if (1) I have an incurable and irreversible condition that will likely result in my death within a relatively short time, or (2) I become unconscious and, to a reasonable degree of medical certainty, I will not regain consciousness, or (3) the apparent risks and burdens of treatment would outweigh the expected benefits. _____ I CHOOSE TO PROLONG MY LIFE. I want my life to be prolonged as long as possible within the limits of generally accepted health care standards. Adv/Dir Page 2 (of 8)
  • 58. PDF/58 3) My Agent May Decide – UNLESS OTHERWISE INDICATED IN THIS FORM, and/or to the extent my wishes are unknown, my agent shall make ALL health care decisions for me in accordance with what my agent determines to be in my best interest – except as follows: _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 4) Treatment for Pain – I direct that treatment for alleviation of pain or discomfort be provided at all times, even if it hastens my death – except as follows: _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 5) Additional Health Care (and/or Mental Health Care) Instructions – _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Adv/Dir Page 3 (of 8)
  • 59. PDF/59 PART “C” – APPOINTMENT OF HEALTH CARE AGENT(S) (NOTE: You MAY NOT to appoint your doctor, an employee of your doctor, or any owner, operator or employee of your health care facility as your Health Care Agent.) THE FOLLOWING ARE APPOINTED to serve as my Health Care Agents per this document successively in the order shown; and unless otherwise noted or appointed in the Additional Instructions section, the following shall also serve as my Conservator, if ever that may be required, in the order shown (NOTICE: If I have not made any name entries in this page then my Health Care Agent[s] identified on my Health Care Power of Attorney shall serve as my agent[s] for this Advance Directive): Primary H/C Agent Appointee: ___________________________________________ Name ___________________________________________ Address ___________________________________________ Phone Number(s) 1st Alternate H/C Agent Appointee: ___________________________________________ Name ___________________________________________ Address ___________________________________________ Phone Number(s) 2nd Alternate H/C Agent Appointee: ___________________________________________ Name ___________________________________________ Address ___________________________________________ Phone Number(s) Adv/Dir Page 4 (of 8)
  • 60. PDF/60 PART “D” – AGENT’S AUTHORITY & ORGAN DONATION (NOTE: You have a right to determine when your agent’s authority becomes effective, which is either [a] when your primary physician determines that you are unable to make decisions on your own or [b] immediately. A notice should be given to your primary physician when an agent’s authority becomes effective): 1) Agent’s Effective Date – My agent’s authority & obligation becomes effective only when my primary physician determines that I am unable to make my own health care decisions (unless I initial the following stipulation). _____ My agent’s authority & obligation becomes effective immediately. 2) Agent's “Post Death” Authority – UNLESS OTHERWISE NOTED in this or a separate document, my agent is authorized to make anatomical gifts, authorize an autopsy, and direct disposition of my remains – except as follows: _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 3) Organ Donation Directive(s) – _____ I DO NOT AUTHORIZE that any organs/tissue/parts be donated from my body. _____ I AUTHORIZE MY AGENT to donate needed organs/tissue/parts from my body. _____ I AUTHORIZE SPECIFIC-PURPOSE donations – shown as circled: Transplant Therapy Research Education _____ I AUTHORIZE CERTAIN LIMITED donations as follows: ______________________________________________________________________ _____________________________________________________________________ ______________________________________________________________________ Adv/Dir Page 5 (of 8)
  • 61. PDF/61 PART “E” – OTHER HEALTH CARE DOCUMENTS (NOTE: A "Health Care Power of Attorney” is any document you may have executed to appoint an agent to make certain health care decisions on your behalf when you are unable to do so. A “Living Will” is any document you may have executed to state your wishes as to the extension or termination of your life when in a terminal condition of such that you are unable to make such a decision.) 1) Health Care Power of Attorney – Initial one or more as applicable: _____ I have executed a Health Care Power of Attorney and IT IS TO REMAIN IN EFFECT. Notwithstanding, if any provision selected in this Advance Directive is not consistent with the provisions in my Health Care Power of Attorney then any such conflicting provision selected in this Advance Directive shall instead apply. _____ I have previously executed a Health Care Power of Attorney and I NOW REVOKE IT. Notwithstanding this revocation, if my medical treatment is being administered in a jurisdiction that otherwise requires the application of a portion or all of the terms of my Health Care Power of Attorney then any such required stipulations therein shall apply. _____ I currently DO NOT have a separate Health Care Power of Attorney. 2) Living Will – Initial one or more as applicable: _____ I have executed a Living Will and IT IS TO REMAIN IN EFFECT. Notwithstanding, if any provision that I have selected in this Advance Directive is determined to be in conflict with any provision in my Living Will then any such conflicting provision selected in my Advance Directive herein shall apply. _____ I have previously executed a Living Will and I NOW REVOKE IT in its entirety. Notwithstanding this revocation, if my medical treatment is being administered in a jurisdiction that necessitates the application of a part or all of the terms of my Living Will then any such required stipulations of my Living Will shall apply. _____ I currently DO NOT have a separate Living Will. 3) Additional Information Regarding “Other Documents” – _____________________________________________________________________ _____________________________________________________________________ Adv/Dir Page 6 (of 8)
  • 62. PDF/62 PART ”F” – Appointment of Primary & Alternate Physician (NOTE: You have a right to designate a primary physician as applied to this directive. If you appoint a primary physician [and an alternate physician] who is not then available to act in that capacity on your behalf then the physician who would be attending to you at that time shall be allowed to act instead in their behalf): Initial As Applicable: _____ I DO NOT DESIGNATE a primary physician. _____ I DESIGNATE a primary physician, as follows: ___________________________________________ Name ___________________________________________ Address ___________________________________________ Phone Number _____ I ALSO DESIGNATE an alternate physician as my physician if my primary physician named above is not willing, able, or reasonably available to act as my physician: ___________________________________________ Name ___________________________________________ Address ___________________________________________ Phone Number Adv/Dir Page 7 (of 8)
  • 63. PDF/63 I hereby declare that I have executed this Advance Directive on this day, the ______ day of __________________, 2013, consisting of eight (8) pages including the "information” page (1) and this acknowledgement page. x________________________________ JOHN W. DOE The Declarant signing this Advance Directive (i) is personally known to us or has provided proof of his identity, (ii) signed or acknowledged his signature on this Advance Directive in our presence, (iii) appears to be of sound mind and not under duress, fraud or undue influence, (iv) has not appointed either of us as health care representative or alternative representative as provided herein, and (v) is not a patient for whom either of us is an attending physician. x________________________________ _________________________________ Witness Address x________________________________ _________________________________ Witness Address - ACKNOWLEDGEMENT - STATE OF ARIZONA COUNTY OF MARICPOA On this ______ day of ________________, 2013, before me, _____________________, the undersigned, personally appeared JOHN W. DOE who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument and acknowledged to me that he executed the same in his authorized capacity, and that by his signature executed this instrument and – _________________________________ & _________________________________ who witnessed the Declarant's signature to this instrument and that to the best of their knowledge the Declarant was at the time eighteen (18) or more years of age, of sound mind and under no constraint or undue influence. I certify under PENALTY OF PERJURY under the laws of the State of Arizona that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: ______________________________ (Seal) Adv/Dir Page 8 (of 8) 
  • 64. PDF/64 DURABLE HIPAA STATEMENT – Release & Authorization – I, JOHN W. DOE, the undersigned, being over eighteen (18) years of age, of sound mind and memory and not acting under duress or undue influence, declare this to be my Durable Statement concerning health care privacy issues addressed by certain federal regulations promulgated under the Health Insurance Portability and Accountability Act (HIPAA) of 42 USC §1320d, 45 CFR 160-164, and all other applicable state and federal law and defining regulations. Notwithstanding any other document that I may have signed earlier to the contrary, I hereby consent to the full disclosure of any and all of my medical records by any physician or psychiatrist or any other health care provider as it may be deemed necessary or expedient, from time to time, for the purposes of rendering a medical opinion as to my physical and/or mental inability to act on my own behalf in making personal, health related, financial/fiduciary or other similar decisions. I authorize any physician, health-care professional, dentist, health plan, hospital, clinic, laboratory, pharmacy or other covered health-care provider, any insurance company and the Medical Information Bureau Inc. or other health-care clearinghouse that has provided treatment or services to me, or that has paid for or is seeking payment from me for such services, to give, disclose and release to the agent(s) as hereinafter described, without restriction, ALL of my individually identifiable health information and medical records regarding any past, present or future medical or mental health condition. The persons designated as my agents for purposes of this agreement include: (a) all persons designated as health care agents and/or attorney-in-fact in any Power of Attorney for Health Care, Advance Health Care Directive, or similar document executed by me and/or (b) as trustees under any living trust executed by me. The authority given my agent(s) shall supersede any prior agreement that I may have made with my health-care providers to restrict access to or disclosure of my individually identifiable health information. The authority given my agent has no expiration date and shall expire only in the event that I revoke the authority in writing and deliver it to my health-care provider. I intend for my agent to be treated as I would be with respect to my rights regarding the use and disclosure of my individually identifiable health information or other medical records. x________________________________ JOHN W. DOE HIPAA Page 1 (of 2) 
  • 65. PDF/65 ACKNOWLEDGEMENT STATE OF ARIZONA COUNTY OF MARICPOA On this ______ day of ________________, 2013, before me, _____________________, the undersigned, personally appeared JOHN W. DOE who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument (Durable HIPAA Statement), consisting of 2 pages of which this is the 2nd, and acknowledged to me that he executed the same in his authorized capacity, and that by his signature executed this instrument. I certify under PENALTY OF PERJURY under the laws of the State of Arizona that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: ______________________________ (Seal) HIPAA Page 2 (of 2) 
  • 66. PDF/66 ADVANCE HEALTH CARE DIRECTIVE PART “A” – IMPORTANT INFORMATION / PLEASE READ This is an important legal document. It can control optional but critical decisions about your health care. Before signing, consider these important facts: 1) YOU HAVE THE RIGHT TO NAME A PERSON TO DIRECT AND CONTROL YOUR HEALTH CARE PREFERENCES – REFERRED TO AS YOUR "HEALTH CARE AGENT" – IN PART "C" OF THIS FORM. YOU MAY APPOINT A PRIMARY PHYSICIAN – TO ADMINISTER YOUR HEALTH CARE DIRECTIVES – IN PART “F” OF THIS FORM. 2) YOU CAN WRITE ANY RESTRICTIONS HEREIN THAT YOU MAY WANT ON HOW YOUR AGENT IS TO MAKE DECISIONS ON YOUR BEHALF. YOUR AGENT MUST FOLLOW YOUR DESIRES AS STATED IN THIS DOCUMENT OR OTHERWISE MADE KNOWN BY YOU. IF YOUR DESIRES ARE UNKNOWN, YOUR AGENT IS TO ACT IN YOUR BEST INTEREST. YOUR AGENT CAN RESIGN AT ANY TIME. 3) UNLESS OTHERWISE INDICATED HEREIN OR IN OTHER DOCUMENTATION, YOUR AGENT WILL HAVE THE RIGHT TO: (A) CONSENT OR REFUSE ANY CARE, TREATMENT, OR PROCEDURE TO MAINTAIN, DIAGNOSE, OR OTHERWISE AFFECT YOUR PHYSICAL OR MENTAL CONDITION; (B) SELECT OR DISCHARGE HEALTH CARE PROVIDERS AND INSTITUTIONS; (C) APPROVE OR DISAPPROVE DIAGNOSTIC TESTS, SURGICAL PROCEDURES, AND PROGRAMS OF MEDICATION; (D) DIRECT THE PROVISION, WITHHOLDING, OR WITHDRAWAL OF ARTIFICIAL NUTRITION AND HYDRATION AND ALL OTHER FORMS OF HEALTH CARE, INCLUDING CARDIOPULMONARY RESUSCITATION; (E) MAKE ANATOMICAL GIFTS, (F) AUTHORIZE AN AUTOPSY, AND (G) DIRECT DISPOSITION OF REMAINS. 4) YOU HAVE THE RIGHT TO GIVE SPECIFIC “CHECK THE BOX” & WRITTEN INSTRUCTIONS FOR HEALTH CARE PROVIDERS TO FOLLOW IF YOU BECOME UNABLE TO DIRECT YOUR OWN CARE - BY USING PART "B" OF THIS FORM. 5) THIS FORM IS VALID ONLY IF YOU SIGN IT VOLUNTARILY AND WHEN YOU ARE OF SOUND MIND. IF YOU DO NOT WANT AN ADVANCE DIRECTIVE HEREIN, YOU DO NOT HAVE TO SIGN THIS FORM. 6) UNLESS YOU HAVE LIMITED THE DURATION OF THIS ADVANCE DIRECTIVE, IT WILL NOT EXPIRE. IF YOU HAVE SET AN EXPIRATION DATE AND YOU BECOME UNABLE TO DIRECT YOUR HEALTH CARE AGENT BEFORE THAT DATE, THIS ADVANCE DIRECTIVE WILL NOT EXPIRE UNTIL YOU ARE ABLE TO MAKE THOSE DECISIONS AGAIN. 7) YOU MAY REVOKE THIS DOCUMENT AT ANY TIME. TO DO SO, NOTIFY YOUR AGENT AND YOUR HEALTH CARE PROVIDER OF THE REVOCATION. NOTWITHSTANDING THIS DOCUMENT, YOU HAVE THE RIGHT TO DECIDE ON YOUR OWN HEALTH CARE AS LONG AS YOU ARE ABLE TO DO SO. 8) YOU MAY CROSS OUT WORDS THAT DON'T EXPRESS YOUR WISHES OR ADD WORDS THAT BETTER EXPRESS YOUR WISHES; INITIAL ALL CHANGES YOU MAKE. FOR THIS DOCUMENT TO BE LEGALLY VALID, YOU MUST SIGN IT UNDER A NOTARY PUBLIC. Adv/Dir Page 1 (of 8)
  • 67. PDF/67 PART “B” – HEALTH CARE DIRECTIVES BY: NAME: $SETTLOR$ ADDRESS: 13 Mockingbird Ln CITYSTZIP: Phoenix, AZ 85001 1) I REVOKE ALL PRIOR Advance Directives signed by me. This document shall remain valid and effective in the event that I become incapacitated. A copy and/or an electronic file of this form shall have the same effect as the original document. 2) Close to Death / End of Life – If I am (a) close to death where tube feeding and/or life support would only postpone the moment of my death, and/or (b) unconscious and it is highly unlikely that I will ever regain consciousness again, and/or (c) I have a progressive illness that will be fatal and is in an advanced stage, and I am consistently and permanently unable to communicate by any means, swallow food and water safely, care for myself and recognize loved ones, and it is very unlikely that my condition will substantially improve, then I request that the following actions be taken (or not taken): Initial as applicable (tube feeding): Initial as applicable (life support): _____ I want tube feeding/hydration _____ I want life support _____ As my Agent recommends _____ As my Agent recommends _____ As my Physician recommends _____ As my Physician recommends _____ I want no tube feeding/hydration _____ I want no life support _____ See my written directives herein _____ See my written directives herein (OR) / Initial as applicable (state your general directives): _____ I CHOOSE NOT TO PROLONG MY LIFE – if (1) I have an incurable and irreversible condition that will likely result in my death within a relatively short time, or (2) I become unconscious and, to a reasonable degree of medical certainty, I will not regain consciousness, or (3) the apparent risks and burdens of treatment would outweigh the expected benefits. _____ I CHOOSE TO PROLONG MY LIFE. I want my life to be prolonged as long as possible within the limits of generally accepted health care standards. Adv/Dir Page 2 (of 8)
  • 68. PDF/68 3) My Agent May Decide – UNLESS OTHERWISE INDICATED IN THIS FORM, and/or to the extent my wishes are unknown, my agent shall make ALL health care decisions for me in accordance with what my agent determines to be in my best interest – except as follows: _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 4) Treatment for Pain – I direct that treatment for alleviation of pain or discomfort be provided at all times, even if it hastens my death – except as follows: _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 5) Additional Health Care (and/or Mental Health Care) Instructions – _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Adv/Dir Page 3 (of 8)
  • 69. PDF/69 PART “C” – APPOINTMENT OF HEALTH CARE AGENT(S) (NOTE: You MAY NOT to appoint your doctor, an employee of your doctor, or any owner, operator or employee of your health care facility as your Health Care Agent.) THE FOLLOWING ARE APPOINTED to serve as my Health Care Agents per this document successively in the order shown; and unless otherwise noted or appointed in the Additional Instructions section, the following shall also serve as my Conservator, if ever that may be required, in the order shown (NOTICE: If I have not made any name entries in this page then my Health Care Agent[s] identified on my Health Care Power of Attorney shall serve as my agent[s] for this Advance Directive): Primary H/C Agent Appointee: ___________________________________________ Name ___________________________________________ Address ___________________________________________ Phone Number(s) 1st Alternate H/C Agent Appointee: ___________________________________________ Name ___________________________________________ Address ___________________________________________ Phone Number(s) 2nd Alternate H/C Agent Appointee: ___________________________________________ Name ___________________________________________ Address ___________________________________________ Phone Number(s) Adv/Dir Page 4 (of 8)
  • 70. PDF/70 PART “D” – AGENT’S AUTHORITY & ORGAN DONATION (NOTE: You have a right to determine when your agent’s authority becomes effective, which is either [a] when your primary physician determines that you are unable to make decisions on your own or [b] immediately. A notice should be given to your primary physician when an agent’s authority becomes effective): 1) Agent’s Effective Date – My agent’s authority & obligation becomes effective only when my primary physician determines that I am unable to make my own health care decisions (unless I initial the following stipulation). _____ My agent’s authority & obligation becomes effective immediately. 2) Agent's “Post Death” Authority – UNLESS OTHERWISE NOTED in this or a separate document, my agent is authorized to make anatomical gifts, authorize an autopsy, and direct disposition of my remains – except as follows: _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 3) Organ Donation Directive(s) – _____ I DO NOT AUTHORIZE that any organs/tissue/parts be donated from my body. _____ I AUTHORIZE MY AGENT to donate needed organs/tissue/parts from my body. _____ I AUTHORIZE SPECIFIC-PURPOSE donations – shown as circled: Transplant Therapy Research Education _____ I AUTHORIZE CERTAIN LIMITED donations as follows: ______________________________________________________________________ _____________________________________________________________________ ______________________________________________________________________ Adv/Dir Page 5 (of 8)
  • 71. PDF/71 PART “E” – OTHER HEALTH CARE DOCUMENTS (NOTE: A "Health Care Power of Attorney” is any document you may have executed to appoint an agent to make certain health care decisions on your behalf when you are unable to do so. A “Living Will” is any document you may have executed to state your wishes as to the extension or termination of your life when in a terminal condition of such that you are unable to make such a decision.) 1) Health Care Power of Attorney – Initial one or more as applicable: _____ I have executed a Health Care Power of Attorney and IT IS TO REMAIN IN EFFECT. Notwithstanding, if any provision selected in this Advance Directive is not consistent with the provisions in my Health Care Power of Attorney then any such conflicting provision selected in this Advance Directive shall instead apply. _____ I have previously executed a Health Care Power of Attorney and I NOW REVOKE IT. Notwithstanding this revocation, if my medical treatment is being administered in a jurisdiction that otherwise requires the application of a portion or all of the terms of my Health Care Power of Attorney then any such required stipulations therein shall apply. _____ I currently DO NOT have a separate Health Care Power of Attorney. 2) Living Will – Initial one or more as applicable: _____ I have executed a Living Will and IT IS TO REMAIN IN EFFECT. Notwithstanding, if any provision that I have selected in this Advance Directive is determined to be in conflict with any provision in my Living Will then any such conflicting provision selected in my Advance Directive herein shall apply. _____ I have previously executed a Living Will and I NOW REVOKE IT in its entirety. Notwithstanding this revocation, if my medical treatment is being administered in a jurisdiction that necessitates the application of a part or all of the terms of my Living Will then any such required stipulations of my Living Will shall apply. _____ I currently DO NOT have a separate Living Will. 3) Additional Information Regarding “Other Documents” – _____________________________________________________________________ _____________________________________________________________________ Adv/Dir Page 6 (of 8)
  • 72. PDF/72 PART “F” – Appointment of Primary & Alternate Physician (NOTE: You have a right to designate a primary physician as applied to this directive. If you appoint a primary physician [and an alternate physician] who is not then available to act in that capacity on your behalf then the physician who would be attending to you at that time shall be allowed to act instead in their behalf): Initial As Applicable: _____ I DO NOT DESIGNATE a primary physician. _____ I DESIGNATE a primary physician, as follows: ___________________________________________ Name ___________________________________________ Address ___________________________________________ Phone Number _____ I ALSO DESIGNATE an alternate physician as my physician if my primary physician named above is not willing, able, or reasonably available to act as my physician: ___________________________________________ Name ___________________________________________ Address ___________________________________________ Phone Number Adv/Dir Page 7 (of 8)
  • 73. PDF/73 I hereby declare that I have executed this Advance Directive on this day, the ______ day of __________________, 2013, consisting of eight (8) pages including the "information” page (1) and this acknowledgement page. x________________________________ JANE E. DOE The Declarant signing this Advance Directive (i) is personally known to us or has provided proof of her identity, (ii) signed or acknowledged her signature on this Advance Directive in our presence, (iii) appears to be of sound mind and not under duress, fraud or undue influence, (iv) has not appointed either of us as health care representative or alternative representative as provided herein, and (v) is not a patient for whom either of us is an attending physician. x________________________________ _________________________________ Witness Address x________________________________ _________________________________ Witness Address - ACKNOWLEDGEMENT - STATE OF ARIZONA COUNTY OF MARICPOA On this ______ day of ________________, 2013, before me, _____________________, the undersigned, personally appeared JANE E. DOE who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument and acknowledged to me that she executed the same in her authorized capacity, and that by her signature executed this instrument and – _________________________________ & _________________________________ who witnessed the Declarant's signature to this instrument and that to the best of their knowledge the Declarant was at the time eighteen (18) or more years of age, of sound mind and under no constraint or undue influence. I certify under PENALTY OF PERJURY under the laws of the State of Arizona that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: ______________________________ (Seal) Adv/Dir Page 8 (of 8) 
  • 74. PDF/74 DURABLE HIPAA STATEMENT – Release & Authorization – I, JANE E. DOE, the undersigned, being over eighteen (18) years of age, of sound mind and memory and not acting under duress or undue influence, declare this to be my Durable Statement concerning health care privacy issues addressed by certain federal regulations promulgated under the Health Insurance Portability and Accountability Act (HIPAA) of 42 USC §1320d, 45 CFR 160-164, and all other applicable state and federal law and defining regulations. Notwithstanding any other document that I may have signed earlier to the contrary, I hereby consent to the full disclosure of any and all of my medical records by any physician or psychiatrist or any other health care provider as it may be deemed necessary or expedient, from time to time, for the purposes of rendering a medical opinion as to my physical and/or mental inability to act on my own behalf in making personal, health related, financial/fiduciary or other similar decisions. I authorize any physician, health-care professional, dentist, health plan, hospital, clinic, laboratory, pharmacy or other covered health-care provider, any insurance company and the Medical Information Bureau Inc. or other health-care clearinghouse that has provided treatment or services to me, or that has paid for or is seeking payment from me for such services, to give, disclose and release to the agent(s) as hereinafter described, without restriction, ALL of my individually identifiable health information and medical records regarding any past, present or future medical or mental health condition. The persons designated as my agents for purposes of this agreement include: (a) all persons designated as health care agents and/or attorney-in-fact in any Power of Attorney for Health Care, Advance Health Care Directive, or similar document executed by me and/or (b) as trustees under any living trust executed by me. The authority given my agent(s) shall supersede any prior agreement that I may have made with my health-care providers to restrict access to or disclosure of my individually identifiable health information. The authority given my agent has no expiration date and shall expire only in the event that I revoke the authority in writing and deliver it to my health-care provider. I intend for my agent to be treated as I would be with respect to my rights regarding the use and disclosure of my individually identifiable health information or other medical records. x________________________________ JANE E. DOE HIPAA Page 1 (of 2) 
  • 75. PDF/75 ACKNOWLEDGEMENT STATE OF ARIZONA COUNTY OF MARICPOA On this ______ day of ________________, 2013, before me, _____________________, the undersigned, personally appeared JANE E. DOE who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument (Durable HIPAA Statement), consisting of 2 pages of which this is the 2nd, and acknowledged to me that she executed the same in her authorized capacity, and that by her signature executed this instrument. I certify under PENALTY OF PERJURY under the laws of the State of Arizona that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: ______________________________ (Seal) HIPAA Page 2 (of 2) 
  • 76. PDF/76 ALTERNATIVE "PRO-LIFE" LIVING WILL w/HEALTH CARE DECLARATION I, JOHN W. DOE (the “Declarant”), now residing at Maricpoa County, State of Arizona, being of sound mind and not under or subject to duress, fraud, or undue influence, intending to create a "Pro-Life" Health Care Declaration do voluntarily state my advance instructions relating to my medical treatment and care. I strongly believe in pro-life principles and I do not agree with “Living Wills” and other similar directives biased in favor of death. This Health Care Declaration is to be interpreted in favor of continued life. If I am unable to give directions regarding the use of life-sustaining treatment, it is my intention that this Health Care Declaration shall be honored by my family, physicians and care providers as the final expression of my instructions relating to my medical treatment or care. I am a competent adult who understands and accepts the consequences, purposes and effects of this document. INTENDED APPLICABILITY. The provisions of this Health Care Declaration apply to any diagnosis, whether I am in a terminal condition, a permanently unconscious state or otherwise. These provisions are effective during any period of time in which I am unable to communicate my informed consent because of illness or injury. This Health Care Declaration is valid unless revoked. GENERAL INSTRUCTIONS. Most of what I state here is general in nature since I cannot anticipate all the possible circumstances of a future illness. I direct that those caring for me avoid doing anything which is contrary to my pro-life principles and related Christian principals. If I am in a terminal condition, I ask that I be told of this so that I might prepare myself for death. I instruct each person who may treat me or care for me in illness or injury, or who otherwise may exercise or influence dominion or control over my body, that nothing shall be done or omitted to be done with the intent to cause my death. Notwithstanding any other document I may have signed, I am not to be denied food or water as long as my body is able to assimilate them. Mechanical or artificial means are to be utilized if necessary to assure me food and water. Medical treatment and care are to be provided if necessary to cure, remedy, or relieve the symptoms of my condition. Evaluation of “quality of life” is not to be a factor. I want to be kept clean and comfortable. Adequate efforts should be taken to relieve my pain though I do not want to be overmedicated to the point where I am unable to comprehend my situation and communicate with those around me. I understand the purpose and effect of this document and, after careful deliberation, hereby sign my name to this Health Care Declaration on this ______ day of __________________, 2013. ________________________________ JOHN W. DOE P/L Living Will Page 1 (of 2) 
  • 77. PDF/77 NOTE: THIS "PRO-LIFE" HEALTH CARE DECLARATION SHOULD BE (1) SIGNED BY TWO ELIGIBLE WITNESSES AS DEFINED BELOW WHO ARE PRESENT WHEN YOU SIGN OR ACKNOWLEDGE YOUR SIGNATURE AND (2) ACKNOWLEDGED BEFORE A NOTARY PUBLIC. The Declarant who has signed this Pro-Life Living Will & Health Care Declaration consisting of two pages of which this is the second page (i) is personally known to us or has provided proof of his identity, (ii) signed or acknowledged his signature on this Declaration in our presence, (iii) appears to be of sound mind and not under duress, fraud or undue influence, (iv) has not appointed either of us as health care representative or alternative representative as provided herein, and (v) is not a patient for whom either of us is an attending physician. x________________________________ _________________________________ Witness Address x________________________________ _________________________________ Witness Address - ACKNOWLEDGEMENT - STATE OF ARIZONA COUNTY OF MARICPOA On this ______ day of ________________, 2013, before me, _____________________, the undersigned, personally appeared JOHN W. DOE who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument and acknowledged to me that he executed the same in his authorized capacity, and that by his signature executed this instrument and – _________________________________ & _________________________________ who witnessed the Declarant's signature to this instrument and that to the best of their knowledge the Declarant was at the time eighteen (18) or more years of age, of sound mind and under no constraint or undue influence. I certify under PENALTY OF PERJURY under the laws of the State of Arizona that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: ______________________________ (Seal) P/L Living Will Page 2 (of 2) 
  • 78. PDF/78 ALTERNATIVE "PRO-LIFE" LIVING WILL w/HEALTH CARE DECLARATION I, JANE E. DOE (the “Declarant”), now residing at Maricpoa County, State of Arizona, being of sound mind and not under or subject to duress, fraud, or undue influence, intending to create a "Pro-Life" Health Care Declaration do voluntarily state my advance instructions relating to my medical treatment and care. I strongly believe in pro-life principles and I do not agree with “Living Wills” and other similar directives biased in favor of death. This Health Care Declaration is to be interpreted in favor of continued life. If I am unable to give directions regarding the use of life-sustaining treatment, it is my intention that this Health Care Declaration shall be honored by my family, physicians and care providers as the final expression of my instructions relating to my medical treatment or care. I am a competent adult who understands and accepts the consequences, purposes and effects of this document. INTENDED APPLICABILITY. The provisions of this Health Care Declaration apply to any diagnosis, whether I am in a terminal condition, a permanently unconscious state or otherwise. These provisions are effective during any period of time in which I am unable to communicate my informed consent because of illness or injury. This Health Care Declaration is valid unless revoked. GENERAL INSTRUCTIONS. Most of what I state here is general in nature since I cannot anticipate all the possible circumstances of a future illness. I direct that those caring for me avoid doing anything which is contrary to my pro-life principles and related Christian principals. If I am in a terminal condition, I ask that I be told of this so that I might prepare myself for death. I instruct each person who may treat me or care for me in illness or injury, or who otherwise may exercise or influence dominion or control over my body, that nothing shall be done or omitted to be done with the intent to cause my death. Notwithstanding any other document I may have signed, I am not to be denied food or water as long as my body is able to assimilate them. Mechanical or artificial means are to be utilized if necessary to assure me food and water. Medical treatment and care are to be provided if necessary to cure, remedy, or relieve the symptoms of my condition. Evaluation of “quality of life” is not to be a factor. I want to be kept clean and comfortable. Adequate efforts should be taken to relieve my pain though I do not want to be overmedicated to the point where I am unable to comprehend my situation and communicate with those around me. I understand the purpose and effect of this document and, after careful deliberation, hereby sign my name to this Health Care Declaration on this ______ day of __________________, 2013. _________________________________ JANE E. DOE P/L Living Will Page 1 (of 2) 
  • 79. PDF/79 NOTE: THIS "PRO-LIFE" HEALTH CARE DECLARATION SHOULD BE (1) SIGNED BY TWO ELIGIBLE WITNESSES AS DEFINED BELOW WHO ARE PRESENT WHEN YOU SIGN OR ACKNOWLEDGE YOUR SIGNATURE AND (2) ACKNOWLEDGED BEFORE A NOTARY PUBLIC. The Declarant who has signed this Pro-Life Living Will & Health Care Declaration consisting of two pages of which this is the second page (i) is personally known to us or has provided proof of her identity, (ii) signed or acknowledged her signature on this Declaration in our presence, (iii) appears to be of sound mind and not under duress, fraud or undue influence, (iv) has not appointed either of us as health care representative or alternative representative as provided herein, and (v) is not a patient for whom either of us is an attending physician. x________________________________ _________________________________ Witness Address x________________________________ _________________________________ Witness Address - ACKNOWLEDGEMENT - STATE OF ARIZONA COUNTY OF MARICPOA On this ______ day of ________________, 2013, before me, _____________________, the undersigned, personally appeared JANE E. DOE who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument and acknowledged to me that she executed the same in her authorized capacity, and that by her signature executed this instrument and – _________________________________ & _________________________________ who witnessed the Declarant's signature to this instrument and that to the best of their knowledge the Declarant was at the time eighteen (18) or more years of age, of sound mind and under no constraint or undue influence. I certify under PENALTY OF PERJURY under the laws of the State of Arizona that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: ______________________________ (Seal) P/L Living Will Page 2 (of 2) 
  • 80. PDF/80 ~ LIVING WILL DECLARATION ~ I, JOHN W. DOE, being a resident of Maricpoa County, State of Arizona, and an adult of sound and disposing mind and memory, not acting under duress, menace, fraud or undue influence of any person, do make, publish and declare this to be my Living Will to supplement all other Wills I may execute. Unless My ADVANCE HEALTH CARE DIRECTIVE Provides Otherwise For Specific Instructions Regarding Any Actions and/or Terms Prescribed Herein or That Revokes This Instrument Entirely, I request that this Living Will be used in the event that I am mentally incapacitated with a catastrophic/terminal medical condition. 1. Declaration of Intent. I realize that, when I am conscious and functioning normally with full mental facilities, I have a legal right to accept or reject medical treatment offered to me by doctors, hospitals or other medical instrumentalities. It is my intent with this Living Will to express my commitment and to designate persons (personal agents/representatives) who are legally empowered to act for me when I am unconscious or mentally incapacitated, with full authority from me to make medical decisions for me and to accept or reject medical treatment offered to me. I rely on the constitutional law and desire that this Living Will be enforced even if I am in a state of the United States which has not adopted specific statutes related to the enforcement of Living Wills. 2. Purpose. The purpose of this Living Will is to prevent my remaining assets from being used to unnecessarily prolong my life, and instead be used to benefit those of my family and/or other heirs who benefit from my worldly estate. Also, I desire to avoid the heartache extended to my loved ones, which may be caused by a prolonged illness, and I wish to avoid additional pain and suffering of myself through whatever senses remain. In the unlikely event that this instrument may not be legally binding in the jurisdiction where I may be terminally ill, then I trust that you who care for me will feel morally bound to follow its mandate. It is my decision made after careful consideration. 3. Instruction. If at any time, I should have an incurable injury, disease or illness certified to be a terminal condition, including what is determined to be a permanent vegetative state or an irreversible coma, by two (2) physicians who have personally examined me, one of whom is my attending physician, and the physicians have determined that my death will occur unless life-sustaining procedures would serve only to artificially prolong the dying process, then I direct that life-sustaining procedures be withheld or withdrawn. In such case, I direct that I be permitted to die naturally with only, but not necessarily, the administration of medication or fluids or the performance of medical procedures deemed necessary to provide me with comfortable care - but not, however, if such administration and performance prolongs my life unnaturally. NOTWITHSTANDING, in the absence of my ability to give directions regarding any use, or the termination thereof, of any medication or fluids, I give sole and unhindered discretion and power to my (appointed) Agents of my Durable Power of Attorney for Health Care to make the final decision regarding the use, or termination thereof, of any such hydration or fluids administered to my body. I have made my expression of my legal right to refuse any treatment offered to me, in such case, and I accept the consequences from such refusal. 4. Mechanics of Implementation. In order to implement this Living Will, the following must occur: My family physician, along with one other consulting physician, shall make a finding that: I am unconscious, mentally incompetent or deranged, senile, insane, or otherwise in an abnormal mental condition where I am not reasonably able to make decisions of my own; or, through an accident, a disease, a nervous system disorder or otherwise, I have acquired an irreversible condition resulting in (i) a brain that is dead, (ii) a brain that is damaged to the point where I will not be able to enjoy a reasonably normal life, (iii) a body with damaged organs or parts that will prevent me from enjoying the quality of productive life to which I am accustomed or (iv) a combination of all of these which will prevent me from enjoying the productive life of which I am accustomed. Living Will Page 1 (of 3)
  • 81. PDF/81 4.1. Notwithstanding, if my family physician is not available, then two attending physicians may concur with the consulting physician in the finding. The findings of the physicians will be written on my patient chart or on a dated piece of paper to be placed in my patient file. 4.2. Thereupon, the representative(s) I have first designated to serve per this Living Will – i.e., my HEALTH CARE POWER OF ATTORNEY AGENTS – shall concur and evidence that concurrence on the patient chart or otherwise on the dated paper with the physician's written findings. If my first designated representative or the next is not readily available, then whichever one is the most readily available shall sign an affirmation of the decision. 4.3. If my representative is not physically available, then concurrence may be affirmed by (i) two witnesses over the phone with those witnesses evidencing the consent by writing this in the patient chart or on the dated paper concerning the physician's written findings or (ii) by telegram or other means used for transmitting the written language, a copy of which shall be placed in my medical files. The findings of my doctors and the decision of my representative, once written, shall not be subject to denunciation by anyone at any later date. 5. Persons Designated To Make Decisions. I now hereby authorize the persons whom I have appointed as Agents/Attorneys-in-Fact of my Durable Power of Attorney for Health Care, which I have simultaneously executed with this Living Will, to make the decision conferred upon them by this instrument. Neither the attending physician nor the hospital is required to determine the reason for any absence of the agents I have chosen. Whichever one, if any, of my family representatives who appears is to take the responsibility of making an effort to locate the persons designated with higher priority. However, I trust any of the persons I have named as my agents to make the necessary decisions. I know that whoever makes the decisions will have made every effort to notify all the agents to obtain their concurrence and, if they cannot contact them in time or get concurrence of all parties, they have the authority to make the necessary decisions. I designate these agents also as my guardians ad litem and guardians of my person to sign all documents and bring any legal proceeding that may be necessary to exercise the power and authority vested in them by this Living Will, which includes the power to bring court proceedings for injunctive relief, damages, or other relief if necessary to carry out my wishes expressed in this Living Will without court proceedings. However, if any doctor, hospital, or other medical institution fails to carry out the instructions of my Living Will and the decisions made by my designated agents herein, then I instruct my agents to carry out my instructions and bring immediate court proceedings to enforce this Living Will. I direct that this Living Will be implemented by my designated agents and the attending doctors acting together without the necessity of consulting courts, administrative bodies or hospital committees. 6. Protection for Persons Designated and Those Assisting. As further evidence of my convictions, which have been expressed in this Living Will, I direct that the assets of my estate and my insurance be used to hold harmless from any liability the agents designated and any doctor, hospital or other medical instrumentality that assists in carrying out my instructions of the persons designated by me to do so, except those who have acted with gross negligence or willful misconduct. x________________________________ JOHN W. DOE Living Will Page 2 (of 3) 
  • 82. PDF/82 NOTE: THIS LIVING WILL DECLARATION SHOULD BE SIGNED BY TWO ELIGIBLE WITNESSES AS DEFINED BELOW WHO ARE NOT BENEFICIARIES OF YOUR ESTATE AND PRESENT WHEN YOU SIGN THIS DOCUMENT BEFORE A NOTARY PUBLIC. ACKNOWLEDGEMENT The Declarant signing the foregoing Living Will Declaration is personally known to us or has provided proof of his identity, signed or acknowledged his signature on this document in our presence, appears to be of sound mind and not under duress, fraud or undue influence, has not appointed either of us as his health care representative, has not named either of us as a beneficiary of his estate, and is not a patient for whom either of us is an attending physician. x________________________________ _________________________________ Witness Address x________________________________ _________________________________ Witness Address STATE OF ARIZONA COUNTY OF MARICPOA On this ______ day of ________________, 2013, before me, _____________________, the undersigned, personally appeared JOHN W. DOE who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument and acknowledged to me that he executed the same in his authorized capacity, and that by his signature executed this instrument and – _________________________________ & _________________________________ who witnessed the Declarant's signature to this instrument and that to the best of their knowledge the Declarant was at the time eighteen (18) or more years of age, of sound mind and under no constraint or undue influence. I certify under PENALTY OF PERJURY under the laws of the State of Arizona that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: ___________________________ (Seal) Living Will Page 3 (of 3) 
  • 83. PDF/83 ~ LIVING WILL DECLARATION ~ I, JANE E. DOE, being a resident of Maricpoa County, State of Arizona, and an adult of sound and disposing mind and memory, not acting under duress, menace, fraud or undue influence of any person, do make, publish and declare this to be my Living Will to supplement all other Wills I may execute. Unless My ADVANCE HEALTH CARE DIRECTIVE Provides Otherwise For Specific Instructions Regarding Any Actions and/or Terms Prescribed Herein or That Revokes This Instrument Entirely, I request that this Living Will be used in the event that I am mentally incapacitated with a catastrophic/terminal medical condition. 1. Declaration of Intent. I realize that, when I am conscious and functioning normally with full mental facilities, I have a legal right to accept or reject medical treatment offered to me by doctors, hospitals or other medical instrumentalities. It is my intent with this Living Will to express my commitment and to designate persons (personal agents/representatives) who are legally empowered to act for me when I am unconscious or mentally incapacitated, with full authority from me to make medical decisions for me and to accept or reject medical treatment offered to me. I rely on the constitutional law and desire that this Living Will be enforced even if I am in a state of the United States which has not adopted specific statutes related to the enforcement of Living Wills. 2. Purpose. The purpose of this Living Will is to prevent my remaining assets from being used to unnecessarily prolong my life, and instead be used to benefit those of my family and/or other heirs who benefit from my worldly estate. Also, I desire to avoid the heartache extended to my loved ones, which may be caused by a prolonged illness, and I wish to avoid additional pain and suffering of myself through whatever senses remain. In the unlikely event that this instrument may not be legally binding in the jurisdiction where I may be terminally ill, then I trust that you who care for me will feel morally bound to follow its mandate. It is my decision made after careful consideration. 3. Instruction. If at any time, I should have an incurable injury, disease or illness certified to be a terminal condition, including what is determined to be a permanent vegetative state or an irreversible coma, by two (2) physicians who have personally examined me, one of whom is my attending physician, and the physicians have determined that my death will occur unless life-sustaining procedures would serve only to artificially prolong the dying process, then I direct that life-sustaining procedures be withheld or withdrawn. In such case, I direct that I be permitted to die naturally with only, but not necessarily, the administration of medication or fluids or the performance of medical procedures deemed necessary to provide me with comfortable care - but not, however, if such administration and performance prolongs my life unnaturally. NOTWITHSTANDING, in the absence of my ability to give directions regarding any use, or the termination thereof, of any medication or fluids, I give sole and unhindered discretion and power to my (appointed) Agents of my Durable Power of Attorney for Health Care to make the final decision regarding the use, or termination thereof, of any such hydration or fluids administered to my body. I have made my expression of my legal right to refuse any treatment offered to me, in such case, and I accept the consequences from such refusal. 4. Mechanics of Implementation. In order to implement this Living Will, the following must occur: My family physician, along with one other consulting physician, shall make a finding that: I am unconscious, mentally incompetent or deranged, senile, insane, or otherwise in an abnormal mental condition where I am not reasonably able to make decisions of my own; or, through an accident, a disease, a nervous system disorder or otherwise, I have acquired an irreversible condition resulting in (i) a brain that is dead, (ii) a brain that is damaged to the point where I will not be able to enjoy a reasonably normal life, (iii) a body with damaged organs or parts that will prevent me from enjoying the quality of productive life to which I am accustomed or (iv) a combination of all of these which will prevent me from enjoying the productive life of which I am accustomed. Living Will Page 1 (of 3)
  • 84. PDF/84 4.1. Notwithstanding, if my family physician is not available, then two attending physicians may concur with the consulting physician in the finding. The findings of the physicians will be written on my patient chart or on a dated piece of paper to be placed in my patient file. 4.2. Thereupon, the representative(s) I have first designated to serve per this Living Will – i.e., my HEALTH CARE POWER OF ATTORNEY AGENTS – shall concur and evidence that concurrence on the patient chart or otherwise on the dated paper with the physician's written findings. If my first designated representative or the next is not readily available, then whichever one is the most readily available shall sign an affirmation of the decision. 4.3. If my representative is not physically available, then concurrence may be affirmed by (i) two witnesses over the phone with those witnesses evidencing the consent by writing this in the patient chart or on the dated paper concerning the physician's written findings or (ii) by telegram or other means used for transmitting the written language, a copy of which shall be placed in my medical files. The findings of my doctors and the decision of my representative, once written, shall not be subject to denunciation by anyone at any later date. 5. Persons Designated To Make Decisions. I now hereby authorize the persons whom I have appointed as Agents/Attorneys-in-Fact of my Durable Power of Attorney for Health Care, which I have simultaneously executed with this Living Will, to make the decision conferred upon them by this instrument. Neither the attending physician nor the hospital is required to determine the reason for any absence of the agents I have chosen. Whichever one, if any, of my family representatives who appears is to take the responsibility of making an effort to locate the persons designated with higher priority. However, I trust any of the persons I have named as my agents to make the necessary decisions. I know that whoever makes the decisions will have made every effort to notify all the agents to obtain their concurrence and, if they cannot contact them in time or get concurrence of all parties, they have the authority to make the necessary decisions. I designate these agents also as my guardians ad litem and guardians of my person to sign all documents and bring any legal proceeding that may be necessary to exercise the power and authority vested in them by this Living Will, which includes the power to bring court proceedings for injunctive relief, damages, or other relief if necessary to carry out my wishes expressed in this Living Will without court proceedings. However, if any doctor, hospital, or other medical institution fails to carry out the instructions of my Living Will and the decisions made by my designated agents herein, then I instruct my agents to carry out my instructions and bring immediate court proceedings to enforce this Living Will. I direct that this Living Will be implemented by my designated agents and the attending doctors acting together without the necessity of consulting courts, administrative bodies or hospital committees. 6. Protection for Persons Designated and Those Assisting. As further evidence of my convictions, which have been expressed in this Living Will, I direct that the assets of my estate and my insurance be used to hold harmless from any liability the agents designated and any doctor, hospital or other medical instrumentality that assists in carrying out my instructions of the persons designated by me to do so, except those who have acted with gross negligence or willful misconduct. x________________________________ JANE E. DOE Living Will Page 2 (of 3) 
  • 85. PDF/85 NOTE: THIS LIVING WILL DECLARATION SHOULD BE SIGNED BY TWO ELIGIBLE WITNESSES AS DEFINED BELOW WHO ARE NOT BENEFICIARIES OF YOUR ESTATE AND PRESENT WHEN YOU SIGN THIS DOCUMENT BEFORE A NOTARY PUBLIC. ACKNOWLEDGEMENT The Declarant signing the foregoing Living Will Declaration is personally known to us or has provided proof of her identity, signed or acknowledged her signature on this document in our presence, appears to be of sound mind and not under duress, fraud or undue influence, has not appointed either of us as her health care representative, has not named either of us as a beneficiary of her estate, and is not a patient for whom either of us is an attending physician. x________________________________ _________________________________ Witness Address x________________________________ _________________________________ Witness Address STATE OF ARIZONA COUNTY OF MARICPOA On this ______ day of ________________, 2013, before me, _____________________, the undersigned, personally appeared JANE E. DOE who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument and acknowledged to me that she executed the same in her authorized capacity, and that by her signature executed this instrument and – _________________________________ & _________________________________ who witnessed the Declarant's signature to this instrument and that to the best of their knowledge the Declarant was at the time eighteen (18) or more years of age, of sound mind and under no constraint or undue influence. I certify under PENALTY OF PERJURY under the laws of the State of Arizona that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: ___________________________ (Seal) Living Will Page 3 (of 3) 