Declaration made this ____ day of _________, ____, I,____________________., willfully and voluntarily make known my desire that my dying not be artificially prolonged under the circumstances set forth below, and I do hereby declare that, if at any time I am incapacitated and _______ I have a terminal condition, or _______ I have an end-stage condition, or _______ I am in a persistent vegetative state, and if my primary physician and another consulting physician have determined that there is no reasonable medical probability of my recovery from such condition, I direct that life-prolonging procedures be withheld or withdrawn when the application of such procedures would serve only to prolong artificially the process of dying, and that I be permitted to die naturally with only the administration of medication or the performance of any medical procedure deemed necessary to provide me with comfort and care or to alleviate pain.
It is my intention that this declaration be honored by my family and physician as the final expression of my legal right to refuse medical or surgical treatment and to accept the consequences for such refusal.
In the event that I have been determined to be unable to provide express and informed consent regarding the withholding, withdrawal, or continuation of life-prolonging procedures, I wish to designate, as my surrogate to carry out the provisions of this declaration:
I understand the full import of this declaration, and I am emotionally and mentally competent to make this declaration.
DURABLE POWER OF ATTORNEY
I,______________________., of ______________________________(hereinafter referred to as PRINCIPAL), designate_____________________________, (hereinafter referred to as AGENT), to be my attorney-in-fact and agent.
Authority of Agent. I hereby grant to AGENT full power and authority to act for me in any lawful way with respect to the powers enumerated below.
Except as otherwise limited by applicable law or by this durable power of attorney, AGENT has full power and authority to perform, without prior court approval, and may take all necessary actions to exercise, any power herein granted as fully as I might or could do if personally present. This power is not diminished even though AGENT may be acting individually or on behalf of any other person or entity interested in the same matters. All acts done under this power by AGENT shall bind me, my heirs, devisees, and personal representatives. This power is nondelegable. I hereby ratify and confirm that AGENT shall lawfully have, by virtue of this durable power of attorney, the powers herein granted, specifically, the authority to:
a. forgive, request, demand, sue for, recover, collect, receive, and hold all sums of money, debts, dues, commercial paper, checks, drafts, accounts, deposits, legacies, bequests, devises, notes, interests, stock certificates, bonds, dividends, certificates of deposit, annuities, pensions, profit sharing, retirement, social security, insurance, and other contractual benefits and proceeds, intangible and tangible property and property rights and any demands whatsoever, liquidated or unliquidated, that I now or hereafter own or that are due, owing, or payable or belonging to me or in which I may now have or hereafter acquire an interest.
b. have, use, and take all lawful means and equitable and legal remedies and proceedings in my name for the collection and recovery of any property now or hereafter owned by me, and adjust, sell, compromise, and agree for the same, and execute and deliver for me, on my behalf and in my name, all endorsements, releases, receipts, or other sufficient discharges for the same.
c. conduct investment transactions as provided in section 709.2208(2), Florida Statutes; and acquire, purchase, invest, reinvest, exchange, grant options to sell, and sell and convey personal property, tangible or intangible, or interests therein, for such price and on such terms and conditions as AGENT shall deem proper, including, without limitation, stocks, bonds, warrants, debentures, commodities, precious metals, futures, currencies, and investment funds, including common trust funds, in domestic and foreign markets.
d. execute stock powers or similar documents and delegate to a transfer agent or similar person the authority to register any stocks, bonds, or other securities either into or out of my name or my nominee’s name.
e. redeem bonds issued by the United States Government or any of its agencies or any other bonds.
f. acquire, purchase, exchange, grant options to sell, and sell and convey any and all of my real estate, lands, tenements, leases, leaseholds or other property in the nature of real estate, or any part or parcel thereof, which I now own or may hereafter acquire, or interests therein, including my homestead real property, at public or private sale, for such price and on such terms and conditions as AGENT shall deem proper, and execute any and all documents necessary to effectuate the same, including but not limited to contracts, deeds, affidavits, bills of sale, assignments, and closing statements; provided, however, that if I am married, AGENT may not convey or dispose of my homestead property without joinder of my spouse or my spouse’s legal guardian. (Joinder by my spouse may be accomplished by the exercise of authority in a durable power of attorney executed by my spouse, and either my spouse or I may appoint the other as attorney-in-fact.)
g. maintain, repair, improve, invest, manage, partition, insure, rent, lease, encumber, and in any manner deal with any real or personal property, tangible or intangible, or any interest therein, that I now own or may hereafter acquire, in my name and for my benefit, upon such terms and conditions that AGENT shall deem proper, and execute, acknowledge, and deliver all instruments necessary to effectuate the foregoing.
h. conduct banking transactions as provided in section 709.2208(1), Florida Statutes.
i. borrow from time to time such sums of money upon such terms and conditions as AGENT shall deem appropriate for, or in relation to, any of the purposes or objects described herein, upon the security of any of my property, whether real or personal or otherwise, and, for such purposes, to give, execute, deliver, and acknowledge mortgages with such power and provisions as AGENT may think proper, and also such notes, bonds, or other instruments as may be necessary or proper in connection therewith; provided, however, that if I am married, AGENT shall not mortgage my homestead property without joinder of my spouse or my spouse’s legal guardian. (Joinder by my spouse may be accomplished by the exercise of authority in a durable power of attorney executed by my spouse, and either my spouse or I may appoint the other as attorney-in-fact.)
j. apply for a certificate of title on, and endorse and transfer title to, any automobile, truck, recreational vehicle, off-road vehicle, van, motorcycle, or other motor vehicle, airplane, or vessel, and to represent in such transfer or assignment that the title to said motor vehicle, airplane, or vessel is free and clear of all liens and encumbrances except those specifically set forth in such transfer or assignment.
k. conduct or participate in any lawful business of whatever nature for me and in my name; execute partnership agreements and amendments thereto; incorporate, reorganize, merge, consolidate, recapitalize, sell, liquidate, or dissolve any business; enter into voting trusts and other agreements or subscriptions; elect or employ officers, directors, and agents; carry out the provisions of any agreement for the sale of any business interest or stock therein; exercise voting rights with respect to stock, either in person or proxy; and exercise stock options.
l. transfer any or all assets of mine to any revocable trust created by me as to which trust I am, during my life, a primary income or principal beneficiary.
m. withdraw from any trust, whether revocable or irrevocable, in which I have a current beneficial interest, such amounts of principal or accrued or collected but undistributed income of such trusts as I would be permitted to receive or withdraw, pursuant to any right of receipt or withdrawal contained in such trusts.
n. make, execute, and file any and all declarations, joint or separate returns, waivers, consents, claims, and other instruments or forms (including, without limitation, IRS Form 2848: Power of Attorney) relating to federal, state, municipal, and other taxes or assessments, including income, transfer, property, excise, and other taxes of whatever nature and whether imposed or required by any domestic or foreign authority, and in connection with any such taxes or assessments due or claimed or believed to be due from me or in respect of any property or rights that I may own or in which I may have any interest.
o. represent me before any office of the Internal Revenue Service, state agency, or any other governmental or municipal body or authority of whatever nature, domestic or foreign, and conduct and transact any case, claim, or other matter whatsoever in connection therewith; receive confidential information regarding tax matters for all periods, whether before or after the execution of this instrument; and make tax elections.
p. have access at any time or times to any safe-deposit box rented by me, wheresoever located, and remove all or any part of the contents thereof, and surrender or relinquish said safe-deposit box, and any institution in which any such safe-deposit box may be located shall not incur any liability to me or my estate as a result of permitting AGENT to exercise this power.
q. exercise any statutory rights or elections, including, but not limited to, any rights or elections in any probate or similar proceeding to which I am or may become entitled.
r. employ as investment counsel, custodians, brokers, accountants, appraisers, attorneys-at-law or other agents such persons, firms, or organizations, including AGENT or AGENT’s firm, as deemed necessary or desirable; pay such persons, firms, or organizations such compensation as is deemed reasonable; and determine whether to act on the advice of any such agent without liability for acting or failing to act thereon.
AGENT is also authorized, if I have initialed the specific act below, to:
( _____ ) a. make gifts to charitable organizations or to or in trust for my spouse or any descendant of mine in connection with estate, gift, generation-skipping transfer, income, or other tax planning for me or to qualify me for any government assistance program; provided, however, that no gift may be made to AGENT other than for AGENT’s health and maintenance or to discharge AGENT’s legal obligations.
( _____ ) b. consent to any gift, use any gift-splitting provision or tax election, and pay gift taxes, but only if in furtherance of my estate plan or my desire to minimize taxes.
( _____ ) c. create one or more inter vivos trusts of which I am an income or principal beneficiary.
( _____ ) d. with respect to a trust created by or on behalf of the PRINCIPAL, amend, modify, revoke, or terminate a trust created by me or on my behalf, but only if the trust instrument explicitly provides for amendment, modification, revocation, or termination by the settlor’s agent.
( _____ ) e. create or change rights of survivorship.
( _____ ) f. create or change a beneficiary designation.
( _____ ) g. waive the PRINCIPAL’s right to be a beneficiary of a joint and survivor annuity, including a survivor benefit under a retirement plan.
( _____ ) h. renounce or disclaim any powers of appointment or property passing to me by testate or intestate succession or by inter vivos transfer.
Interpretation and Governing Law. This instrument is to be construed and interpreted as a general durable power of attorney. This instrument is executed and delivered in the State of Florida, and the laws of Florida shall govern all questions as to the validity of this power and the construction of its provisions. However, it is my intention that this power of attorney shall be exercisable in any other state or jurisdiction where I may have any property or interests in property.
Third-Party Reliance. Third parties may rely on the representations of AGENT as to all matters relating to any power granted to AGENT, and no person who may act in reliance on the representations of AGENT shall incur any liability to me or to my estate, beneficiaries, or joint owners as a result of permitting AGENT to exercise any power prior to receipt of a written notice of revocation, suspension, petition to determine my incapacity, partial or complete termination of this power, or my death. Any third party may rely on a duly executed counterpart of this instrument, or a copy certified by AGENT to be a true copy of the original hereof, as fully and completely as if such third party had received the original of this instrument.
Disability of Principal. This durable power of attorney is not terminated by my subsequent incapacity, except as provided in section 709, Florida Statutes, or any successor provision of law.
IN WITNESS WHEREOF, I have set my hand and seal on __________, ________.
SIGNED, SEALED, AND DELIVERED
IN THE PRESENCE OF:
STATE OF FLORIDA
COUNTY OF _______________________________
The foregoing instrument was acknowledged before me on ______ __, ______ by ____________________, who identified this instrument as her Durable Power of Attorney and signed the instrument willingly. _____________________ is personally known to me or has produced ____________________ as identification.
Notary Public – State of Florida
DESIGNATION OF HEALTH CARE SURROGATE
I, ____________________, designate as my health care surrogate under s. 765.202, Florida Statutes:
If my health care surrogate is not willing, able, or reasonably available to perform his duties, I designate as my alternate health care surrogate:
INSTRUCTIONS FOR HEALTH CARE
I authorize my health care surrogate to:
_______ Receive any of my health information, whether oral or recorded in any form or medium, that:
1. Is created or received by a health care provider, health care facility, health plan, public health authority, employer, life insurer, school or university, or health care clearinghouse; and
2. Relates to my past, present, or future physical or mental health or condition; the provision of health care to me; or the past, present, or future payment for the provision of health care to me.
I further authorize my health care surrogate to:
_______ Make all health care decisions for me, which means he or she has the authority to:
1. Provide informed consent, refusal of consent, or withdrawal of consent to any and all of my health care, including life-prolonging procedures.
2. Apply on my behalf for private, public, government, or veterans’ benefits to defray the cost of health care.
3. Access my health information reasonably necessary for the health care surrogate to make decisions involving my health care and to apply for benefits for me.
4. Decide to make an anatomical gift pursuant to part V of chapter 765, Florida Statutes.
While I have decisionmaking capacity, my wishes are controlling and my physicians and health care providers must clearly communicate to me the treatment plan or any change to the treatment plan prior to its implementation.
To the extent I am capable of understanding, my health care surrogate shall keep me reasonably informed of all decisions that he or she has made on my behalf and matters concerning me.
IT IS MY STATED DESIRE TO BE CARED FOR AT HOME AS LONG AS POSSIBLE . MY HEALTH CARE SURROGATE SHALL TAKE THIS INTO CONSIDERATION IN ANY DECEISION THAT THEY MAKE.
THIS HEALTH CARE SURROGATE DESIGNATION IS NOT AFFECTED BY MY SUBSEQUENT INCAPACITY EXCEPT AS PROVIDED IN CHAPTER 765, FLORIDA STATUTES.
PURSUANT TO SECTION 765.104, FLORIDA STATUTES, I UNDERSTAND THAT I MAY, AT ANY TIME WHILE I RETAIN MY CAPACITY, REVOKE OR AMEND THIS DESIGNATION BY:
(1) SIGNING A WRITTEN AND DATED INSTRUMENT WHICH EXPRESSES MY INTENT TO AMEND OR REVOKE THIS DESIGNATION;
(2) PHYSICALLY DESTROYING THIS DESIGNATION THROUGH MY OWN ACTION OR BY THAT OF ANOTHER PERSON IN MY PRESENCE AND UNDER MY DIRECTION;
(3) VERBALLY EXPRESSING MY INTENTION TO AMEND OR REVOKE THIS DESIGNATION; OR
(4) SIGNING A NEW DESIGNATION THAT IS MATERIALLY DIFFERENT FROM THIS DESIGNATION.
MY HEALTH CARE SURROGATE’S AUTHORITY BECOMES EFFECTIVE WHEN MY PRIMARY PHYSICIAN DETERMINES THAT I AM UNABLE TO MAKE MY OWN HEALTH CARE DECISIONS UNLESS I INITIAL EITHER OR BOTH OF THE FOLLOWING BOXES:
IF I INITIAL THIS BOX [ ], MY HEALTH CARE SURROGATE’S AUTHORITY TO RECEIVE MY HEALTH INFORMATION TAKES EFFECT IMMEDIATELY.
IF I INITIAL THIS BOX [ ], MY HEALTH CARE SURROGATE’S AUTHORITY TO MAKE HEALTH CARE DECISIONS FOR ME TAKES EFFECT IMMEDIATELY. PURSUANT TO SECTION 765.204(3), FLORIDA STATUTES, ANY INSTRUCTIONS OR HEALTH CARE DECISIONS I MAKE, EITHER VERBALLY OR IN WRITING, WHILE I POSSESS CAPACITY SHALL SUPERSEDE ANY INSTRUCTIONS OR HEALTH CARE DECISIONS MADE BY MY SURROGATE THAT ARE IN MATERIAL CONFLICT WITH THOSE MADE BY ME.
STATE OF FLORIDA
Subscribed, sworn, and acknowledged before me by________________________, and subscribed and sworn to before me by _____________________________________, and ______________________________________, the witnesses, all of whom have produced driver’s license as identification on__________________.
Notary Public – State of Florida
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