1) The document is John Doe's last will and testament, which leaves his entire estate to his wife Jane Doe if she survives him.
2) If Jane Doe does not survive John, his estate will be divided equally among his children James and Joyce. Any children of James or Joyce who predecease John will take their parent's share.
3) The will provides signatures lines and instructions for signing by John Doe, witnesses, and a notary public.
This document is Jane Doe's last will and testament. It names Billy Jo Doe as the primary beneficiary to receive Jane's entire probate estate. If Billy Jo Doe does not survive Jane, then Billy Jo Doe's portion of the estate will be distributed to his surviving legal children. The will also establishes how Jane's tangible personal property and specific gifts will be distributed. It provides instructions for how the estate is to be divided and distributed to beneficiaries.
This document provides instructions for implementing and understanding a Dynamic Trust Portfolio for the Smith family. It includes documents related to a revocable living trust, powers of attorney, healthcare directives, and a will. The portfolio contains 10 sections that cover topics like trust administration, schedules of assets, powers of attorney, living wills, and distribution of assets upon death. It is intended to help the Smith family organize their estate planning documents and provide guidance to their successor trustee.
This document summarizes John Sample-Demo's Dynamic Trust Portfolio, which includes a revocable living trust, powers of attorney, living will, and other documents to manage his assets and medical decisions. The portfolio is designed to protect John's assets from unnecessary expenses during his lifetime and when transferring assets after death, while allowing him to maintain control. The summary provides explanations of each document and section to help John implement and fund the trust properly. It also serves as a reference for his successor trustee.
This document provides information about income tax in India. It discusses the history of income tax dating back over 3,000 years to ancient Egypt and Greece. It was first introduced in India in 1860. The document outlines the various income tax authorities in India and provides definitions of key terms like assessee, person, assessment year, and previous year. It also describes the different types of income tax return forms (ITR) individuals and organizations can file. Other sections cover interest charges, advance tax payment due dates, and details of the Income Disclosure Scheme of 2016 for declaring undisclosed income and paying tax at concessional rates.
Este documento es una solicitud de reconocimiento de pago con error presentada ante la SUNAT. En ella, un contribuyente o su representante legal solicita la corrección de un error en el pago de un tributo, proporcionando detalles como el período tributario, código de tributo, fecha y monto del pago incorrecto. Adicionalmente, el contribuyente firma la solicitud y autoriza a otra persona a presentarla en su nombre ante la SUNAT.
La consecución parcial o total de financiación para llevar a cabo un proyecto es básico en los tiempos que corren. Si tienes un proyecto claro y definido hay que buscar si existe una subvención pública y solicitarla.... justificarla..... y hacer realidad tu proyecto.
El documento describe la letra de cambio y el pagaré. Una letra de cambio es un documento en el que el librador ordena al librado el pago de una cantidad de dinero en una fecha determinada, y puede transmitirse a un beneficiario. Un pagaré es un documento en el que una persona se compromete a pagar una cantidad a otra en una fecha acordada. Ambos documentos deben contener la denominación, importe, fecha de vencimiento, lugar de pago y firma.
Este documento lista as principais contas contábeis utilizadas pela ESAF/CESPE/FCC de acordo com a Lei 11.941/09, dividindo-as entre ativo, passivo, patrimônio líquido e resultado. Fornece também observações sobre a classificação de algumas contas e referências bibliográficas.
This document is Jane Doe's last will and testament. It names Billy Jo Doe as the primary beneficiary to receive Jane's entire probate estate. If Billy Jo Doe does not survive Jane, then Billy Jo Doe's portion of the estate will be distributed to his surviving legal children. The will also establishes how Jane's tangible personal property and specific gifts will be distributed. It provides instructions for how the estate is to be divided and distributed to beneficiaries.
This document provides instructions for implementing and understanding a Dynamic Trust Portfolio for the Smith family. It includes documents related to a revocable living trust, powers of attorney, healthcare directives, and a will. The portfolio contains 10 sections that cover topics like trust administration, schedules of assets, powers of attorney, living wills, and distribution of assets upon death. It is intended to help the Smith family organize their estate planning documents and provide guidance to their successor trustee.
This document summarizes John Sample-Demo's Dynamic Trust Portfolio, which includes a revocable living trust, powers of attorney, living will, and other documents to manage his assets and medical decisions. The portfolio is designed to protect John's assets from unnecessary expenses during his lifetime and when transferring assets after death, while allowing him to maintain control. The summary provides explanations of each document and section to help John implement and fund the trust properly. It also serves as a reference for his successor trustee.
This document provides information about income tax in India. It discusses the history of income tax dating back over 3,000 years to ancient Egypt and Greece. It was first introduced in India in 1860. The document outlines the various income tax authorities in India and provides definitions of key terms like assessee, person, assessment year, and previous year. It also describes the different types of income tax return forms (ITR) individuals and organizations can file. Other sections cover interest charges, advance tax payment due dates, and details of the Income Disclosure Scheme of 2016 for declaring undisclosed income and paying tax at concessional rates.
Este documento es una solicitud de reconocimiento de pago con error presentada ante la SUNAT. En ella, un contribuyente o su representante legal solicita la corrección de un error en el pago de un tributo, proporcionando detalles como el período tributario, código de tributo, fecha y monto del pago incorrecto. Adicionalmente, el contribuyente firma la solicitud y autoriza a otra persona a presentarla en su nombre ante la SUNAT.
La consecución parcial o total de financiación para llevar a cabo un proyecto es básico en los tiempos que corren. Si tienes un proyecto claro y definido hay que buscar si existe una subvención pública y solicitarla.... justificarla..... y hacer realidad tu proyecto.
El documento describe la letra de cambio y el pagaré. Una letra de cambio es un documento en el que el librador ordena al librado el pago de una cantidad de dinero en una fecha determinada, y puede transmitirse a un beneficiario. Un pagaré es un documento en el que una persona se compromete a pagar una cantidad a otra en una fecha acordada. Ambos documentos deben contener la denominación, importe, fecha de vencimiento, lugar de pago y firma.
Este documento lista as principais contas contábeis utilizadas pela ESAF/CESPE/FCC de acordo com a Lei 11.941/09, dividindo-as entre ativo, passivo, patrimônio líquido e resultado. Fornece também observações sobre a classificação de algumas contas e referências bibliográficas.
CLASE 2- DISPOSICIONES GENERALES Y CAPITULO I.pptxCalendarioAlma
Este documento contiene disposiciones generales sobre el impuesto a las personas físicas en México. Establece que las personas físicas residentes en México que obtengan ingresos están obligadas a pagar el impuesto. También cubre a personas físicas residentes en el extranjero que realicen actividades empresariales o presten servicios personales en México a través de un establecimiento permanente. Define conceptos como ingresos, partes relacionadas y establece procedimientos como la discrepancia fiscal cuando los gastos superen los ingresos
Este documento discute las características y clasificaciones de las medidas cautelares en el proceso de amparo. Explica que la "suspensión del acto" mencionada en la ley de amparo original se refería a una medida cautelar de no innovar para conservar el statu quo. Sin embargo, los jueces han interpretado esta disposición de manera más amplia para incluir medidas cautelares innovativas que alteran el statu quo, lo cual el autor considera correcto siempre que se cumplan los requisitos para su emisión. El documento también anal
Plano de contas contabeis conforme Lei 11638/2007wiltonroberto
O documento fornece uma sugestão de plano de contas detalhado de acordo com a Lei 11.638/2007, dividindo as contas entre ativo circulante, ativo não circulante, passivo circulante, passivo não circulante e patrimônio líquido, e fornecendo subcontas para cada item principal.
La letra de cambio es un título valor que ordena a una persona denominada girado pagar una suma de dinero a un tercero llamado tomador. Tiene características como ser abstracta, literal, a la orden y formal. Los sujetos que intervienen son el girador, girado, aceptante, tomador y endosante. Requiere denominación, fecha, orden de pago, nombre del girado y tomador. Puede girarse a la orden del girador, de un tercero o a cargo de un tercero, y el girador es responsable por la aceptación o
El documento habla sobre el contenido de los testamentos. Explica que un testamento debe contener disposiciones patrimoniales por causa de muerte como la designación de un sucesor o heredero. También señala que se requiere certeza en la designación de la persona favorecida y que pueden existir diferentes tipos de instituciones como las condicionales, a plazo o las sustituciones hereditarias.
El documento discute el uso del crédito fiscal cuando una empresa realiza operaciones gravadas y no gravadas con IGV. Explica que existen dos métodos para determinar el crédito fiscal aplicable: 1) La identificación, que permite usar el crédito fiscal completo si las compras pueden asignarse a operaciones gravadas. 2) La prorrata, un método de cálculo, se usa cuando no es posible discriminar las compras. El documento analiza estos métodos en detalle y cita las leyes y reglamentos relevantes.
This document provides an overview of incomes chargeable to tax under the head "Income from other sources" in India. It discusses various types of incomes taxable under this residuary head, including dividends, lottery winnings, monetary gifts, non-monetary gifts, property received without/with inadequate consideration, rent, interest from securities, and amounts from life insurance policies. It also outlines expenses that are allowed and not allowed as deductions while computing income under this head, and provides a brief summary of a relevant case law on the tax treatment of loans given in the normal course of business.
Sesión 2 (2) - Transmisión de los Títulos Valores - Garantías Cambiarias (1)....Brayan Perez
El documento habla sobre diferentes tipos de garantías para títulos valores, incluyendo garantías personales como el aval y la fianza, y garantías reales. Explica que el aval es una garantía donde una tercera persona se obliga a pagar la deuda de manera solidaria con el deudor original. La fianza también es una obligación accesoria donde el fiador responde de manera subsidiaria. Las garantías reales no requieren autorización del deudor pero deben registrarse para asegurar el cumplimiento de la obligación.
This document provides an overview of investment fund structures in India and compliance requirements. It discusses various types of fund vehicles like offshore and onshore funds. It also covers key areas like choice of fund jurisdiction, documentation requirements, registration and approvals with Indian regulators, ongoing compliance, and certification needs. The presentation further elaborates on topics like different types of investors in India, tax implications, and investment structures for foreign venture capital investors.
The document provides instructions for viewing Form 26AS, an Indian income tax form, in 9 steps: visit the Income Tax Department website, click "View Form 26AS", log in with an email and password or register an account, confirm, select the form and assessment year, choose a format, and click "View/Download". It also provides contact information for a tax help website that offers free guides on related topics.
Este documento presenta un resumen de la Ley de Títulos Valores de Perú. Explica los conceptos básicos como qué es un título valor, los tipos de títulos valores (a la orden, al portador y nominativos), los principios que rigen los títulos valores como incorporación, literalidad, formalidad y autonomía, y los derechos que otorgan. También define conceptos como emisor, obligado, tenedor y endoso, y describe las características de los títulos valores emitidos al portador y a la orden.
El documento describe diferentes tipos de títulos valores como cheques, letras de cambio y pagarés. Explica las características de cada uno, incluyendo quien es el librador, librado y beneficiario. También describe los elementos necesarios que deben contener cada tipo de título y cómo pueden ser transferidos o negociados.
This document is an individual death claim form for a life insurance policy. It requests details about the deceased policyholder such as name, date and cause of death. It also requires information about the claimant filing the claim, their relationship to the deceased, and their bank account details to process a payout. The claimant is required to provide documentation like the death certificate, policy documents, and ID proofs to support the claim.
Sample California revocable living trust with spendthrift provisionLegalDocsPro
This is a preview of a sample California living trust for a husband and wife. The actual sample living trust has a spendthrift provision and is sold by LegalDocsPro.
Numerous federal requirements govern retirement plan distributions upon the death of a participant. Other rules give a plan sponsor flexibility in the payment features it wishes to include. The determination of who receives a participant's death benefit falls into both camps. Accordingly, the qualified plan document and its underlying forms should contain tightly drafted language that is compliant with the current regulations and clear enough to guide the plan administrator on practical execution. This article examines some of the key issues that qualified retirement plan sponsors should consider when reviewing and updating plan documents and administrative procedures to ensure compliance with current beneficiary designation rules.
Prenuptial Agreement Lawyer
How to Draft a Prenup You Never Plan to Use
Presented by Melinda M. Previtera, Esquire with
Petrelli Previtera, LLC
https://www.petrellilaw.com/our-team/melinda-m-previtera/
Our Offices in Philadelphia & New Jersey
PHILADELPHIA (215) 523-6900 1845
Walnut Street, 19th Floor Philadelphia, PA 19103
NORRISTOWN (610) 924-2870
516 DeKalb Street, Suite C Norristown, PA 19401 Details
DOYLESTOWN (267) 938-4480
40 E Court Street 2nd Floor Doylestown, PA 18901
VOORHEES, NJ (201) 655-7204 1020
1020 Laurel Oak Road, Suite 203, Voorhees, NJ 08043
CHICAGO (312) 252-2085
180 North Stetson Suite 3500 Chicago, IL 60601
PRINCETON, NJ (609) 917 9560
29 Emmons Drive Suite E-30 Princeton, NJ 08540
LINWOOD, NJ (609) 375-0351
210 New Road #15 Linwood, NJ 08221
This document summarizes Form 8332, which allows a custodial parent to release their claim to an exemption for their child so that the noncustodial parent can claim the exemption. It provides instructions for the custodial parent to release the exemption for the current year (Part I), future years (Part II), or revoke a previous release for future years (Part III). Key details include defining custodial and noncustodial parents, the special rule for divorced/separated parents that allows the noncustodial parent to claim the exemption if certain conditions are met, and specifics on which pages of a pre-2009 divorce decree can substitute for using the form.
This document summarizes Arizona statutes related to wills and trusts, including how divorce, murder, statutory allowances, an elective share, intestacy, an omitted spouse, market fluctuations, trustee issues, beneficiary changes, and legal changes can impact estate plans. It provides an example of how unequal asset distribution between children due to market changes could frustrate a decedent's intent to provide roughly equal benefits. The document emphasizes reviewing jurisdiction-specific laws regarding the application of revocation statutes to irrevocable trusts.
This document discusses the importance of drafting a Qualified Domestic Relations Order (QDRO) when dividing retirement assets in a divorce. It notes that many clients are awarded retirement assets in their divorce decrees but never actually receive the funds because a QDRO was never prepared. Drafting a QDRO can be complex due to regulations in the tax code and ERISA. The document provides an overview of the process for identifying retirement assets, valuing them, dividing them in a marital settlement agreement, drafting the QDRO, getting it approved, and distributing the funds while addressing any tax implications. It emphasizes that failing to complete this QDRO step can result in clients losing out on substantial retirement funds awarded to them.
This document establishes a permanent family charitable trust by a husband and wife. It outlines how the trust's revenues will be used each year for 20 years and thereafter in perpetuity. 50% of revenues will be reinvested in the principal. 30% will be distributed to the founders' children, grandchildren, and their offspring according to Islamic law. 20% will be given to an Islamic nonprofit. If no qualified offspring exist, 50% will be reinvested and 50% given to an Islamic nonprofit. The distribution of shares to qualified offspring is explained in detail according to Islamic law and succession.
This document contains certifications and disclosures required for medical billing. It states that the billing information is true and accurate, and that required authorizations and certifications are on file. It covers certifications for third party benefits, private rooms, physician certifications, and signatures authorizing the release of information. It also contains certifications specific to Medicare, Medicaid, TRICARE and other health plans regarding the medical necessity of services and billing other insurances first before submitting claims.
CLASE 2- DISPOSICIONES GENERALES Y CAPITULO I.pptxCalendarioAlma
Este documento contiene disposiciones generales sobre el impuesto a las personas físicas en México. Establece que las personas físicas residentes en México que obtengan ingresos están obligadas a pagar el impuesto. También cubre a personas físicas residentes en el extranjero que realicen actividades empresariales o presten servicios personales en México a través de un establecimiento permanente. Define conceptos como ingresos, partes relacionadas y establece procedimientos como la discrepancia fiscal cuando los gastos superen los ingresos
Este documento discute las características y clasificaciones de las medidas cautelares en el proceso de amparo. Explica que la "suspensión del acto" mencionada en la ley de amparo original se refería a una medida cautelar de no innovar para conservar el statu quo. Sin embargo, los jueces han interpretado esta disposición de manera más amplia para incluir medidas cautelares innovativas que alteran el statu quo, lo cual el autor considera correcto siempre que se cumplan los requisitos para su emisión. El documento también anal
Plano de contas contabeis conforme Lei 11638/2007wiltonroberto
O documento fornece uma sugestão de plano de contas detalhado de acordo com a Lei 11.638/2007, dividindo as contas entre ativo circulante, ativo não circulante, passivo circulante, passivo não circulante e patrimônio líquido, e fornecendo subcontas para cada item principal.
La letra de cambio es un título valor que ordena a una persona denominada girado pagar una suma de dinero a un tercero llamado tomador. Tiene características como ser abstracta, literal, a la orden y formal. Los sujetos que intervienen son el girador, girado, aceptante, tomador y endosante. Requiere denominación, fecha, orden de pago, nombre del girado y tomador. Puede girarse a la orden del girador, de un tercero o a cargo de un tercero, y el girador es responsable por la aceptación o
El documento habla sobre el contenido de los testamentos. Explica que un testamento debe contener disposiciones patrimoniales por causa de muerte como la designación de un sucesor o heredero. También señala que se requiere certeza en la designación de la persona favorecida y que pueden existir diferentes tipos de instituciones como las condicionales, a plazo o las sustituciones hereditarias.
El documento discute el uso del crédito fiscal cuando una empresa realiza operaciones gravadas y no gravadas con IGV. Explica que existen dos métodos para determinar el crédito fiscal aplicable: 1) La identificación, que permite usar el crédito fiscal completo si las compras pueden asignarse a operaciones gravadas. 2) La prorrata, un método de cálculo, se usa cuando no es posible discriminar las compras. El documento analiza estos métodos en detalle y cita las leyes y reglamentos relevantes.
This document provides an overview of incomes chargeable to tax under the head "Income from other sources" in India. It discusses various types of incomes taxable under this residuary head, including dividends, lottery winnings, monetary gifts, non-monetary gifts, property received without/with inadequate consideration, rent, interest from securities, and amounts from life insurance policies. It also outlines expenses that are allowed and not allowed as deductions while computing income under this head, and provides a brief summary of a relevant case law on the tax treatment of loans given in the normal course of business.
Sesión 2 (2) - Transmisión de los Títulos Valores - Garantías Cambiarias (1)....Brayan Perez
El documento habla sobre diferentes tipos de garantías para títulos valores, incluyendo garantías personales como el aval y la fianza, y garantías reales. Explica que el aval es una garantía donde una tercera persona se obliga a pagar la deuda de manera solidaria con el deudor original. La fianza también es una obligación accesoria donde el fiador responde de manera subsidiaria. Las garantías reales no requieren autorización del deudor pero deben registrarse para asegurar el cumplimiento de la obligación.
This document provides an overview of investment fund structures in India and compliance requirements. It discusses various types of fund vehicles like offshore and onshore funds. It also covers key areas like choice of fund jurisdiction, documentation requirements, registration and approvals with Indian regulators, ongoing compliance, and certification needs. The presentation further elaborates on topics like different types of investors in India, tax implications, and investment structures for foreign venture capital investors.
The document provides instructions for viewing Form 26AS, an Indian income tax form, in 9 steps: visit the Income Tax Department website, click "View Form 26AS", log in with an email and password or register an account, confirm, select the form and assessment year, choose a format, and click "View/Download". It also provides contact information for a tax help website that offers free guides on related topics.
Este documento presenta un resumen de la Ley de Títulos Valores de Perú. Explica los conceptos básicos como qué es un título valor, los tipos de títulos valores (a la orden, al portador y nominativos), los principios que rigen los títulos valores como incorporación, literalidad, formalidad y autonomía, y los derechos que otorgan. También define conceptos como emisor, obligado, tenedor y endoso, y describe las características de los títulos valores emitidos al portador y a la orden.
El documento describe diferentes tipos de títulos valores como cheques, letras de cambio y pagarés. Explica las características de cada uno, incluyendo quien es el librador, librado y beneficiario. También describe los elementos necesarios que deben contener cada tipo de título y cómo pueden ser transferidos o negociados.
This document is an individual death claim form for a life insurance policy. It requests details about the deceased policyholder such as name, date and cause of death. It also requires information about the claimant filing the claim, their relationship to the deceased, and their bank account details to process a payout. The claimant is required to provide documentation like the death certificate, policy documents, and ID proofs to support the claim.
Sample California revocable living trust with spendthrift provisionLegalDocsPro
This is a preview of a sample California living trust for a husband and wife. The actual sample living trust has a spendthrift provision and is sold by LegalDocsPro.
Numerous federal requirements govern retirement plan distributions upon the death of a participant. Other rules give a plan sponsor flexibility in the payment features it wishes to include. The determination of who receives a participant's death benefit falls into both camps. Accordingly, the qualified plan document and its underlying forms should contain tightly drafted language that is compliant with the current regulations and clear enough to guide the plan administrator on practical execution. This article examines some of the key issues that qualified retirement plan sponsors should consider when reviewing and updating plan documents and administrative procedures to ensure compliance with current beneficiary designation rules.
Prenuptial Agreement Lawyer
How to Draft a Prenup You Never Plan to Use
Presented by Melinda M. Previtera, Esquire with
Petrelli Previtera, LLC
https://www.petrellilaw.com/our-team/melinda-m-previtera/
Our Offices in Philadelphia & New Jersey
PHILADELPHIA (215) 523-6900 1845
Walnut Street, 19th Floor Philadelphia, PA 19103
NORRISTOWN (610) 924-2870
516 DeKalb Street, Suite C Norristown, PA 19401 Details
DOYLESTOWN (267) 938-4480
40 E Court Street 2nd Floor Doylestown, PA 18901
VOORHEES, NJ (201) 655-7204 1020
1020 Laurel Oak Road, Suite 203, Voorhees, NJ 08043
CHICAGO (312) 252-2085
180 North Stetson Suite 3500 Chicago, IL 60601
PRINCETON, NJ (609) 917 9560
29 Emmons Drive Suite E-30 Princeton, NJ 08540
LINWOOD, NJ (609) 375-0351
210 New Road #15 Linwood, NJ 08221
This document summarizes Form 8332, which allows a custodial parent to release their claim to an exemption for their child so that the noncustodial parent can claim the exemption. It provides instructions for the custodial parent to release the exemption for the current year (Part I), future years (Part II), or revoke a previous release for future years (Part III). Key details include defining custodial and noncustodial parents, the special rule for divorced/separated parents that allows the noncustodial parent to claim the exemption if certain conditions are met, and specifics on which pages of a pre-2009 divorce decree can substitute for using the form.
This document summarizes Arizona statutes related to wills and trusts, including how divorce, murder, statutory allowances, an elective share, intestacy, an omitted spouse, market fluctuations, trustee issues, beneficiary changes, and legal changes can impact estate plans. It provides an example of how unequal asset distribution between children due to market changes could frustrate a decedent's intent to provide roughly equal benefits. The document emphasizes reviewing jurisdiction-specific laws regarding the application of revocation statutes to irrevocable trusts.
This document discusses the importance of drafting a Qualified Domestic Relations Order (QDRO) when dividing retirement assets in a divorce. It notes that many clients are awarded retirement assets in their divorce decrees but never actually receive the funds because a QDRO was never prepared. Drafting a QDRO can be complex due to regulations in the tax code and ERISA. The document provides an overview of the process for identifying retirement assets, valuing them, dividing them in a marital settlement agreement, drafting the QDRO, getting it approved, and distributing the funds while addressing any tax implications. It emphasizes that failing to complete this QDRO step can result in clients losing out on substantial retirement funds awarded to them.
This document establishes a permanent family charitable trust by a husband and wife. It outlines how the trust's revenues will be used each year for 20 years and thereafter in perpetuity. 50% of revenues will be reinvested in the principal. 30% will be distributed to the founders' children, grandchildren, and their offspring according to Islamic law. 20% will be given to an Islamic nonprofit. If no qualified offspring exist, 50% will be reinvested and 50% given to an Islamic nonprofit. The distribution of shares to qualified offspring is explained in detail according to Islamic law and succession.
This document contains certifications and disclosures required for medical billing. It states that the billing information is true and accurate, and that required authorizations and certifications are on file. It covers certifications for third party benefits, private rooms, physician certifications, and signatures authorizing the release of information. It also contains certifications specific to Medicare, Medicaid, TRICARE and other health plans regarding the medical necessity of services and billing other insurances first before submitting claims.
(1) The document is a general forbearance request form for the William D. Ford Federal Direct Loan Program that allows borrowers experiencing temporary financial hardship to request suspending or reducing loan payments.
(2) The borrower identifies their hardship as financial difficulties and requests temporarily stopping payments for a period between specified dates not exceeding 12 months.
(3) By signing, the borrower certifies the accuracy of the request, agrees to provide additional documentation, and understands that interest will accrue and potentially be capitalized during the forbearance period.
This document is a stipulation for dismissal with prejudice of a civil rights lawsuit filed by the American Civil Liberties Union of Hawaii and Pamela Lichty against Dean H. Seki, Comptroller of the Department of Accounting and General Services for the State of Hawaii. It includes a settlement agreement requiring the defendant to pay attorneys fees and costs, cease enforcement of certain permit requirements for expressive activities on state property, revise relevant administrative rules and policies, and provide periodic updates on implementation to plaintiffs' counsel. The purpose is to ensure individuals can engage in expressive activities on state property with constitutional time, place and manner restrictions.
This document contains a visitor application for a U.S. Forest Service international exchange program. It requests biographical information such as name, date of birth, citizenship, contact details, emergency contacts, and residential history. It also requests information about the applicant's occupation, employer, program details including dates and location, funding sources, dependents, insurance, and intellectual property rights. The applicant agrees to terms regarding their participation, maintaining legal status, health insurance coverage, responsibility for taxes and bills, reporting requirements, and addressing changes by signing the document.
This document provides instructions for submitting a claim form as part of a class action settlement involving Groupon vouchers purchased between November 2008 and December 2011. Eligible purchasers who submit claim forms and documentation will receive a settlement voucher valid for 130 days to redeem expired Groupon vouchers. The claim form requests information about voucher purchases, a declaration that the purchaser meets eligibility criteria, and a signature agreeing to the settlement terms.
Bankruptcy individual filing needed forms list = instructions individualsall4yhwh
This document provides instructions for completing bankruptcy forms for individuals. It explains key terms used in the forms, important things to remember when filling out the forms, and summaries of specific forms including Schedules A/B through J, the Statement of Financial Affairs, Means Test forms, and more. The introduction emphasizes that completing the forms is only part of the bankruptcy process and strongly encourages hiring an attorney for legal advice and accurate form completion.
This document is a vendor acknowledgment form for Kasserian Ingera Preservations LLC. It outlines the confidentiality requirements for any information received from the company. It also describes the independent contractor relationship between the vendor and the company. The vendor must comply with the company's procedures manual and maintain appropriate insurance. Background checks are required for any individuals performing services for the company. The form addresses issues like chargebacks, the company's ability to perform work if the vendor fails to do so, non-disparagement, time being of the essence, choice of law, and compliance with all applicable laws and regulations.
Alexander Elbanna - Founder at Digital World ExchangeAlexander Elbanna
Alexander Elbanna Digital World Exchange is a decentralized social media blockchain, putting you back in control of your data and communication. We are an off the grid blockchain solution that doesn’t require internet or cell service to power of application. We have built a privacy-focused social media marketplace for identity, messaging, filestorage, content creation and payments.You control what you want to store, who you want to communicate with and what friends and networks to publish.
(1) Cal.Educ.Code §56507 - Provides notice requirements for parties intending to use attorneys in special education due process hearings. Allows for attorney fee awards to prevailing parties.
(2) Cal.Fam.Code §3452 - Allows courts to award necessary expenses including attorney fees to prevailing parties in family law cases, unless inappropriate. Prohibits imposing costs on states without authorization.
(3) Cal.Food&Agric.Code §226 - Establishes annual funding for Bureau of Market Enforcement litigation expenses. Outlines cost sharing between funds if annual amount is exceeded. Awards costs and fees to prevailing civil parties involving the Bureau.
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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)
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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)
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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)
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(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)
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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)
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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)
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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)
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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)
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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)
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(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)
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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)
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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)
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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)
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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
_________________________________
_________________________________
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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)
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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)
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(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)
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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)
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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)
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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)
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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)
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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)
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(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)
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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)
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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)
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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)
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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)
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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)
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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)
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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)
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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)
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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)