1. Insert all dates where indicated.
2.
If you want more than one agent in sequence, place
their names, addresses, and phone numbers on the blank
lines on page 3.
3.
On 1.2, AGENT’S AUTHORITY, on page 3, you can
leave it blanks in most cases. 1.4 and 1.5 can usually
be left blank.
4.
Most important is 2.1, END OF LIFE DECISIONS. Most
people (90%) check (a) which makes most sense.
5.
Most do not answer questions 2.2 or 2.3.
6.
Most people do not answer PART 4.
7.
PART 5, the signature provision must be signed.
8.
5.3 requires two witnesses who fit the requirements.
At least one of the two witnesses, if you use them,
need to sign 5.4.
9.
If you do not want to use witnesses, go to the last
page and have the notary notarize the signature. This
eliminates the need for one or two witnesses.
10.
SPECIAL WITNESS REQUIREMENT: If the principal is in
a nursing home, the PATIENT ADVOCATE OR OMBUDSMAN
must sign the STATEMENT OF PATIENT ADVOCATE OR OMBUDSMAN.
11.
This form can be photocopied as many times as you
wish, and the copies are as good as the original.
Give copies to your regular doctor and to the hospital
administrator if going into a hospital.
