Jane Doe Will Package

JANE E DOE
Last Will & Testament
– Package –
File# 183046
– Electronic Signatures Verification Status –
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

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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 (ten/10) pages where either (a) 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 / Pages 12 & 13 > PDF/14&15
 Durable Power of Attorney Over Assets / Page 3 & 4 > PDF/20&21
 Durable Power of Attorney for Health Care / Page 4 > PDF/26
 Advanced Health Care Directives / Page 8 > PDF/36
 Durable HIPAA Statement / Pages 1 & 2 > PDF/37&38
 Pro-Life Living Will* / Pages 1 & 2 > PDF/39&40
 Living Will Declaration / Page 3 > PDF/42&43
*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.

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LAST WILL & TESTAMENT
JANE E DOE
I, JANE E DOE, a resident of Maricopa County, State of Arizona, declare that this
document 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 currently unmarried.
Identification of Primary Beneficiaries.
1.2. The name(s) of the primary beneficiary(s) of my Will who shall receive all
of my probate estate – or a portion, if applicable – accordingly as such dispositive
terms are prescribed in Sections 3.1/3.2 et seq. (below) is/are:
BILLY JO DOE
ARTICLE II
– Personal Property Allocations –
Tangible Personal Property.
2.1. I give all of my tangible personal property, including my interest if any
insurance on that property, as provided in Sections 3.1 – 3.4 (infra) of this Will. If
the beneficiaries of my Will are not able to agree on the division and distribution
of my tangible personal property then the Executor of my Will 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 of Personal Property.
2.2. Notwithstanding Section 2.1 (above), if I have made any handwritten entries
on the Directive of Specific Allocations (Page 11 of 13) with my signature therein,
then the specific allocations of such Directive shall apply concerning specific
allocations of my personal property.
LW&T Page 1 (of 13)

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ARTICLE III
– Distribution of My Assets –
Division/Distribution of My Probate Estate.
3.1. 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).
3.2. My Executor shall 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 3.3 (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 3.3, 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 & 3.1/3.2.
(c) In such case of the usage of the Schedule of Other/Alternate Primary
Beneficiaries, the allocations in Sections 1.2 & 3.1/3.2 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 “3.3” / 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 3.3 (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 3 (of 13)

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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 as to allocations/distributions of "in cash"
and/or "in kind":
3.3. SPECIFIC DIRECTIVES. 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 3.2 > > >
Beneficiary Under Age 21.
3.4. 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 4 (of 13)

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Beneficiary Over Age 21.
3.5. 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 3.1/3.2 et seq. (above).
Final Distribution.
3.6. 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 BILLY JO DOE to serve as Executor of my Will.
Waiver of Bond.
4.2. Unless otherwise then required by Arizona state law, no bond or
undertaking shall be required of any Executor nominated herein.
General Powers of My Executor.
4.3. I authorize but not necessary direct my Executor to sell, either at public or
private sale, any property belonging to my estate, either with or without notice,
subject to such confirmation as may be required by law, and to hold, manage and
operate any such property including the investing of surplus money, in any kind
of property, real, personal, or mixed, and every kind of investment.
LW&T Page 5 (of 13)

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(a) Further, such management power includes, but is 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.
(b) My Executor may 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.
4.4. 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.
4.5. 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.
4.6. To the extent permitted by law, and without regard to the resulting effect on
any other provision of this Will, on any person interested in my estate, or 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 6 (of 13)

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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 and administration expenses, as well as all
“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 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 7 (of 13)

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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 8 (of 13)

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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 of an
annuity, retirement plan, IRA, Keogh, pension or profit-sharing plan, insurance
policy or any other Qualified Plan or unqualified retirement plan signed by me; or
any trust created 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 9 (of 13)

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Perpetuities Savings Clause.
6.10. Notwithstanding any other provision of this Will, 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 the time of
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 income 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
with the following "Directive of Specific Personal Property" page. Following this
(final) Article Seven, said "Directive" page, Testator’s signature, and the witnesses’
attestations hereof is a self-proving affidavit (identified on Page 13).
LW&T Page 10 (of 13)

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Directive of Specific Personal Property Allocations
I, JANE E DOE, in accordance with Section 2.2, of Article II, in my Last Will &
Testament, hereby bequeath certain tangible personal property to the persons
identified below respective of each separate item adjacent to the person’s name. All
entries on this page may only be handwritten in by me.
Personal Property Item Recipient
_________________________________ ______________________________
_________________________________ ______________________________
_________________________________ ______________________________
_________________________________ ______________________________
_________________________________ ______________________________
_________________________________ ______________________________
_________________________________ ______________________________
_________________________________ ______________________________
_________________________________ ______________________________
x______________________________
JANE E DOE

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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 MARICOPA
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)


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SELF PROVING AFFIDAVIT
STATE OF ARIZONA
COUNTY OF MARICOPA
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.
Signature: ______________________________ (Seal)


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LOCATER/IDENTIFIER REFERENCE LEDGER
JANE E 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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LOCATER/IDENTIFIER REFERENCE LEDGER
JANE E 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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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, hereby appoint BILLY JO DOE to serve as my lawful
Attorney-in-Fact over assets 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 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/Assets Page 1 (of 4)

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_______ (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
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.

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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


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STATE OF ARIZONA
COUNTY OF MARICOPA
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.
Signature: ___________________________ (Seal)


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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
STATE OF _____________________
COUNTY OF ___________________
On this ______ day of ________________ / _____, before me, _____________________,
the undersigned Notary Public, personally appeared the above named 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.
Signature: ______________________________ (Seal)

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DURABLE POWER OF ATTORNEY
– FOR HEALTH CARE –
I, JANE E DOE, a resident of Maricopa 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 BILLY JO DOE as my true and lawful Attorney-in-Fact agent for
health care.
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.
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.
DPA/Health Page 1 (of 4)

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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.

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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.

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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.
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 MARICOPA
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 –
_________________________________ & _________________________________
Signature: ___________________________ (Seal)


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HEALTH CARE AGENT NOTICE
TO WHOM IT CONCERNS:
I, ________________________________, the undersigned AFFIANT, named as the
Health Care Agent for JANE E DOE, the Principal, in that certain - Durable Power of
Attorney for Health Care document dated -
the ______ day of ________________, ________:
declare and state the following:
I hereby accept this appointment and agree to serve as agent for the Principal concerning
her Health Care decisions in the event that she is incapable in making such decisions herself. I
understand that I have a duty to act consistently with the desires of the Principal as expressed in
such appointment.
I understand that said document gives me authority over health care decisions for her only
if she becomes incapable and that I must act in good faith in exercising my authority under
such appointment. I acknowledge that the principal, if competent, may revoke said Health Care
Power of Attorney at any time and in any manner.
If I choose to withdraw during the time the principal is competent, I must notify JANE E
DOE of my decision. If I choose to withdraw when the principal is incapable of making her
own health care decisions then I must notify her physician.
x________________________________
Affiant
STATE OF _______________________
COUNTY OF _____________________
On this ______ day of _______________, ______, before me, ____________________, the
undersigned, personally appeared the above name 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.
Signature: ______________________________ (Seal)

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PLEASE NOTICE
The following document(s) is referred to as an –
ADVANCE DIRECTIVE for HEALTH CARE
An Advance Directive (for health care) can work with or without a Durable Power of
Attorney for Health Care and is generally used in conjunction with a Living Will (as
does a Health Care Power of Attorney). However, you do not have to fill out and sign
this form.
You may sign the Advance Directive now or at a later date or not at all. Whatever
choice you make, it is recommended that you review the document at your earliest
convenience.
It is not the place or the responsibility of a financial or tax advisor to explain
matters pertaining to health care documents. If you do not understand any of the
components of the Advance Directive or how it works in conjunction with any other
health care document(s) that you may have executed, then it is recommended that you
seek out a doctor or other medical assistant to explain the issues that are unclear to you.
____________________

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ADVANCE HEALTH CARE DIRECTIVE
PART “A” – IMPORTANT INFORMATION / PLEASE READ
This is an important legal document. It can control optional but critical decisions about your
health care. Before signing, consider these important facts:
1) YOU HAVE THE RIGHT TO NAME A PERSON TO DIRECT AND CONTROL YOUR HEALTH
CARE PREFERENCES – REFERRED TO AS YOUR "HEALTH CARE AGENT" – IN PART "C" OF
THIS FORM. YOU MAY APPOINT A PRIMARY PHYSICIAN – TO ADMINISTER YOUR
HEALTH CARE DIRECTIVES – IN PART “F” OF THIS FORM.
2) YOU CAN WRITE ANY RESTRICTIONS HEREIN THAT YOU MAY WANT ON HOW YOUR
AGENT IS TO MAKE DECISIONS ON YOUR BEHALF. YOUR AGENT MUST FOLLOW YOUR
DESIRES AS STATED IN THIS DOCUMENT OR OTHERWISE MADE KNOWN BY YOU. IF
YOUR DESIRES ARE UNKNOWN, YOUR AGENT IS TO ACT IN YOUR BEST INTEREST.
YOUR AGENT CAN RESIGN AT ANY TIME.
3) UNLESS OTHERWISE INDICATED HEREIN OR IN OTHER DOCUMENTATION, YOUR
AGENT WILL HAVE THE RIGHT TO: (A) CONSENT OR REFUSE ANY CARE, TREATMENT,
OR PROCEDURE TO MAINTAIN, DIAGNOSE, OR OTHERWISE AFFECT YOUR PHYSICAL
OR MENTAL CONDITION; (B) SELECT OR DISCHARGE HEALTH CARE PROVIDERS AND
INSTITUTIONS; (C) APPROVE OR DISAPPROVE DIAGNOSTIC TESTS, SURGICAL
PROCEDURES, AND PROGRAMS OF MEDICATION; (D) DIRECT THE PROVISION,
WITHHOLDING, OR WITHDRAWAL OF ARTIFICIAL NUTRITION AND HYDRATION AND
ALL OTHER FORMS OF HEALTH CARE, INCLUDING CARDIOPULMONARY
RESUSCITATION; (E) MAKE ANATOMICAL GIFTS, (F) AUTHORIZE AN AUTOPSY, AND (G)
DIRECT DISPOSITION OF REMAINS.
4) YOU HAVE THE RIGHT TO GIVE SPECIFIC “CHECK THE BOX” & WRITTEN
INSTRUCTIONS FOR HEALTH CARE PROVIDERS TO FOLLOW IF YOU BECOME UNABLE
TO DIRECT YOUR OWN CARE - BY USING PART "B" OF THIS FORM.
5) THIS FORM IS VALID ONLY IF YOU SIGN IT VOLUNTARILY AND WHEN YOU ARE OF
SOUND MIND. IF YOU DO NOT WANT AN ADVANCE DIRECTIVE HEREIN, YOU DO NOT
HAVE TO SIGN THIS FORM.
6) UNLESS YOU HAVE LIMITED THE DURATION OF THIS ADVANCE DIRECTIVE, IT WILL
NOT EXPIRE. IF YOU HAVE SET AN EXPIRATION DATE AND YOU BECOME UNABLE TO
DIRECT YOUR HEALTH CARE AGENT BEFORE THAT DATE, THIS ADVANCE DIRECTIVE
WILL NOT EXPIRE UNTIL YOU ARE ABLE TO MAKE THOSE DECISIONS AGAIN.
7) YOU MAY REVOKE THIS DOCUMENT AT ANY TIME. TO DO SO, NOTIFY YOUR AGENT
AND YOUR HEALTH CARE PROVIDER OF THE REVOCATION. NOTWITHSTANDING THIS
DOCUMENT, YOU HAVE THE RIGHT TO DECIDE ON YOUR OWN HEALTH CARE AS LONG
AS YOU ARE ABLE TO DO SO.
8) YOU MAY CROSS OUT WORDS THAT DON'T EXPRESS YOUR WISHES OR ADD WORDS
THAT BETTER EXPRESS YOUR WISHES; INITIAL ALL CHANGES YOU MAKE. FOR THIS
DOCUMENT TO BE LEGALLY VALID, YOU MUST SIGN IT UNDER A NOTARY PUBLIC.
AdvDir Page 1 (of 8)

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PART “B” – HEALTH CARE DIRECTIVES BY:
NAME: JANE E DOE
ADDRESS: 12 Brown St
CITYSTZIP: Phoenix, AZ 85001
1) I REVOKE ALL PRIOR Advance Directives signed by me. This document shall
remain valid and effective in the event that I become incapacitated. A copy and/or an
electronic file of this form shall have the same effect as the original document.
2) Close to Death / End of Life –
If I am (a) close to death where tube feeding and/or life support would only postpone the
moment of my death, and/or (b) unconscious and it is highly unlikely that I will ever regain
consciousness again, and/or (c) I have a progressive illness that will be fatal and is in an
advanced stage, and I am consistently and permanently unable to communicate by any
means, swallow food and water safely, care for myself and recognize loved ones, and it is
very unlikely that my condition will substantially improve, then I request that the following
actions be taken (or not taken):
Initial as applicable (tube feeding): Initial as applicable (life support):
_____ I want tube feeding/hydration _____ I want life support
_____ As my Agent recommends _____ As my Agent recommends
_____ As my Physician recommends _____ As my Physician recommends
_____ I want no tube feeding/hydration _____ I want no life support
_____ See my written directives herein _____ See my written directives herein
(OR) / Initial as applicable (state your general directives):
_____ I CHOOSE NOT TO PROLONG MY LIFE – if (1) I have an incurable
and irreversible condition that will likely result in my death within a relatively short
time, or (2) I become unconscious and, to a reasonable degree of medical certainty,
I will not regain consciousness, or (3) the apparent risks and burdens of treatment
would outweigh the expected benefits.
_____ I CHOOSE TO PROLONG MY LIFE. I want my life to be prolonged as
long as possible within the limits of generally accepted health care standards.

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3) My Agent May Decide –
UNLESS OTHERWISE INDICATED IN THIS FORM, and/or to the extent my wishes are
unknown, my agent shall make ALL health care decisions for me in accordance with what my
agent determines to be in my best interest – except as follows:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
4) Treatment for Pain –
I direct that treatment for alleviation of pain or discomfort be provided at all times, even if it
hastens my death – except as follows:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
5) Additional Health Care (and/or Mental Health Care) Instructions –
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

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PART “C” – APPOINTMENT OF HEALTH CARE AGENT(S)
(NOTE: You MAY NOT to appoint your doctor, an employee of your doctor, or any owner,
operator or employee of your health care facility as your Health Care Agent.)
THE FOLLOWING ARE APPOINTED to serve as my Health Care Agents per this document
successively in the order shown; and unless otherwise noted or appointed in the Additional
Instructions section, the following shall also serve as my Conservator, if ever that may be
required, in the order shown (NOTICE: If I have not made any name entries in this page
then my Health Care Agent[s] identified on my Health Care Power of Attorney shall serve
as my agent[s] for this Advance Directive):
Primary H/C Agent Appointee:
___________________________________________
Name
___________________________________________
Address
___________________________________________
Phone Number(s)
1st
Alternate H/C Agent Appointee:
___________________________________________
Name
___________________________________________
Address
___________________________________________
Phone Number(s)
2nd
Alternate H/C Agent Appointee:
___________________________________________
Name
___________________________________________
Address
___________________________________________
Phone Number(s)

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PART “D” – AGENT’S AUTHORITY & ORGAN DONATION
(NOTE: You have a right to determine when your agent’s authority becomes effective,
which is either [a] when your primary physician determines that you are unable to make
decisions on your own or [b] immediately. A notice should be given to your primary
physician when an agent’s authority becomes effective):
1) Agent’s Effective Date –
My agent’s authority & obligation becomes effective only when my primary physician
determines that I am unable to make my own health care decisions (unless I initial the
following stipulation).
_____ My agent’s authority & obligation becomes effective immediately.
2) Agent's “Post Death” Authority –
UNLESS OTHERWISE NOTED in this or a separate document, my agent is authorized to
make anatomical gifts, authorize an autopsy, and direct disposition of my remains – except as
follows:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
3) Organ Donation Directive(s) –
_____ I DO NOT AUTHORIZE that any organs/tissue/parts be donated from my body.
_____ I AUTHORIZE MY AGENT to donate needed organs/tissue/parts from my body.
_____ I AUTHORIZE SPECIFIC-PURPOSE donations – shown as circled:
Transplant Therapy Research Education
_____ I AUTHORIZE CERTAIN LIMITED donations as follows:
______________________________________________________________________
_____________________________________________________________________
______________________________________________________________________

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PART “E” – OTHER HEALTH CARE DOCUMENTS
(NOTE: A "Health Care Power of Attorney” is any document you may have executed to
appoint an agent to make certain health care decisions on your behalf when you are unable
to do so. A “Living Will” is any document you may have executed to state your wishes as to
the extension or termination of your life when in a terminal condition of such that you are
unable to make such a decision.)
1) Health Care Power of Attorney –
Initial one or more as applicable:
_____ I have executed a Health Care Power of Attorney and IT IS TO REMAIN IN
EFFECT. Notwithstanding, if any provision selected in this Advance Directive is not
consistent with the provisions in my Health Care Power of Attorney then any such
conflicting provision selected in this Advance Directive shall instead apply.
_____ I have previously executed a Health Care Power of Attorney and I NOW REVOKE
IT. Notwithstanding this revocation, if my medical treatment is being administered in
a jurisdiction that otherwise requires the application of a portion or all of the terms of
my Health Care Power of Attorney then any such required stipulations therein shall
apply.
_____ I currently DO NOT have a separate Health Care Power of Attorney.
2) Living Will –
Initial one or more as applicable:
_____ I have executed a Living Will and IT IS TO REMAIN IN EFFECT.
Notwithstanding, if any provision that I have selected in this Advance Directive is
determined to be in conflict with any provision in my Living Will then any such
conflicting provision selected in my Advance Directive herein shall apply.
_____ I have previously executed a Living Will and I NOW REVOKE IT in its entirety.
Notwithstanding this revocation, if my medical treatment is being administered in a
jurisdiction that necessitates the application of a part or all of the terms of my Living
Will then any such required stipulations of my Living Will shall apply.
_____ I currently DO NOT have a separate Living Will.
3) Additional Information Regarding “Other Documents” –
_____________________________________________________________________
_____________________________________________________________________

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PART ”F” – Appointment of Primary & Alternate Physician
(NOTE: You have a right to designate a primary physician as applied to this directive. If
you appoint a primary physician [and an alternate physician] who is not then available to
act in that capacity on your behalf then the physician who would be attending to you at that
time shall be allowed to act instead in their behalf):
Initial As Applicable:
_____ I DO NOT DESIGNATE a primary physician.
_____ I DESIGNATE a primary physician, as follows:
___________________________________________
Name
___________________________________________
Address
___________________________________________
Phone Number
_____ I ALSO DESIGNATE an alternate physician as my physician if my primary physician
named above is not willing, able, or reasonably available to act as my physician:
___________________________________________
Name
___________________________________________
Address
___________________________________________
Phone Number

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I hereby declare that I have executed this Advance Directive on this day, the ______ day of
__________________, 2013, consisting of eight (8) pages including the "information” page (1)
and this acknowledgement page.
x________________________________
JANE E DOE
The Declarant signing this Advance Directive (i) is personally known to us or has provided
proof of her identity, (ii) signed or acknowledged her signature on this Advance Directive in
our presence, (iii) appears to be of sound mind and not under duress, fraud or undue influence,
(iv) has not appointed either of us as health care representative or alternative representative as
provided herein, and (v) is not a patient for whom either of us is an attending physician.
x________________________________ _________________________________
Witness Address
x________________________________ _________________________________
Witness Address
- ACKNOWLEDGEMENT -
STATE OF ARIZONA
COUNTY OF MARICOPA
instrument and –
_________________________________ & _________________________________
Signature: ___________________________ (Seal)


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DURABLE HIPAA STATEMENT
– Release & Authorization –
I, JANE E DOE, the undersigned, being over eighteen (18) years of age, of sound mind
and memory and not acting under duress or undue influence, declare this to be my Durable
Statement concerning health care privacy issues addressed by certain federal regulations
promulgated under the Health Insurance Portability and Accountability Act (HIPAA) of 42
USC §1320d, 45 CFR 160-164, and all other applicable state and federal law and defining
regulations. Notwithstanding any other document that I may have signed earlier to the contrary,
I hereby consent to the full disclosure of any and all of my medical records by any physician or
psychiatrist or any other health care provider as it may be deemed necessary or expedient, from
time to time, for the purposes of rendering a medical opinion as to my physical and/or mental
inability to act on my own behalf in making personal, health related, financial/fiduciary or other
similar decisions.
I authorize any physician, health-care professional, dentist, health plan, hospital, clinic,
laboratory, pharmacy or other covered health-care provider, any insurance company and the
Medical Information Bureau Inc. or other health-care clearinghouse that has provided treatment
or services to me, or that has paid for or is seeking payment from me for such services, to give,
disclose and release to the agent(s) as hereinafter described, without restriction, ALL of my
individually identifiable health information and medical records regarding any past, present or
future medical or mental health condition. The persons designated as my agents for purposes of
this agreement include: (a) all persons designated as health care agents and/or attorney-in-fact
in any Power of Attorney for Health Care, Advance Health Care Directive, or similar document
executed by me and/or (b) as trustees under any living trust executed by me.
The authority given my agent(s) shall supersede any prior agreement that I may have made
with my health-care providers to restrict access to or disclosure of my individually identifiable
health information. The authority given my agent has no expiration date and shall expire only
in the event that I revoke the authority in writing and deliver it to my health-care provider. I
intend for my agent to be treated as I would be with respect to my rights regarding the use and
disclosure of my individually identifiable health information or other medical records.
x________________________________
JANE E DOE
HIPAA Page 1 (of 2)
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ACKNOWLEDGEMENT
STATE OF ARIZONA
COUNTY OF MARICOPA
evidence to be the person whose name is subscribed to the within instrument (Durable HIPAA
Statement), consisting of two (2) pages of which this is the 2nd, and acknowledged to me that she
executed the same in her authorized capacity, and that by her signature executed this instrument.
Signature: ______________________________ (Seal)
HIPAA Page 2 (of 2)
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ALTERNATIVE "PRO-LIFE" LIVING WILL
w/HEALTH CARE DECLARATION
I, JANE E DOE (the “Declarant”), now residing at Maricopa County, State of Arizona,
being of sound mind and not under or subject to duress, fraud, or undue influence, intending to
create a "Pro-Life" Health Care Declaration do voluntarily state my advance instructions
relating to my medical treatment and care. I strongly believe in pro-life principles and I do not
agree with “Living Wills” and other similar directives biased in favor of death. This Health
Care Declaration is to be interpreted in favor of continued life. If I am unable to give directions
regarding the use of life-sustaining treatment, it is my intention that this Health Care
Declaration shall be honored by my family, physicians and care providers as the final
expression of my instructions relating to my medical treatment or care. I am a competent adult
who understands and accepts the consequences, purposes and effects of this document.
INTENDED APPLICABILITY. The provisions of this Health Care Declaration apply to any
diagnosis, whether I am in a terminal condition, a permanently unconscious state or otherwise.
These provisions are effective during any period of time in which I am unable to communicate
my informed consent because of illness or injury. This Health Care Declaration is valid unless
revoked.
GENERAL INSTRUCTIONS. Most of what I state here is general in nature since I cannot
anticipate all the possible circumstances of a future illness. I direct that those caring for me
avoid doing anything which is contrary to my pro-life principles and related Christian
principals. If I am in a terminal condition, I ask that I be told of this so that I might prepare
myself for death. I instruct each person who may treat me or care for me in illness or injury, or
who otherwise may exercise or influence dominion or control over my body, that nothing shall
be done or omitted to be done with the intent to cause my death. Notwithstanding any other
document I may have signed, I am not to be denied food or water as long as my body is able
to assimilate them. Mechanical or artificial means are to be utilized if necessary to assure me
food and water. Medical treatment and care are to be provided if necessary to cure, remedy, or
relieve the symptoms of my condition. Evaluation of “quality of life” is not to be a factor. I
want to be kept clean and comfortable. Adequate efforts should be taken to relieve my pain
though I do not want to be overmedicated to the point where I am unable to comprehend my
situation and communicate with those around me.
I understand the purpose and effect of this document and, after careful deliberation, hereby
sign my name to this Health Care Declaration on this ______ day of __________________,
2013.
___________________________________
JANE E DOE
P/L Living Will Page 1 (of 2)
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NOTE: THIS "PRO-LIFE" HEALTH CARE DECLARATION SHOULD BE SIGNED, IF SO
CHOSEN, BY TWO ELIGIBLE WITNESSES AS DEFINED BELOW WHO ARE PRESENT
WHEN YOU SIGN OR ACKNOWLEDGE YOUR SIGNATURE AND ACKNOWLEDGED
BEFORE A NOTARY PUBLIC.
- ACKNOWLEDGEMENT -
The Declarant who has signed this Pro-Life Living Will & Health Care Declaration
consisting of two pages of which this is the second page (i) is personally known to us or has
provided proof of her identity, (ii) signed or acknowledged her signature on this Declaration in
our presence, (iii) appears to be of sound mind and not under duress, fraud or undue influence,
(iv) has not appointed either of us as health care representative or alternative representative as
provided herein, and (v) is not a patient for whom either of us is an attending physician.
x________________________________ _________________________________
Witness Address
x________________________________ _________________________________
Witness Address
STATE OF ARIZONA
COUNTY OF MARICOPA
instrument and –
_________________________________ & _________________________________
Signature: ___________________________ (Seal)
P/L Living Will Page 2 (of 2)
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~ LIVING WILL DECLARATION ~
I, JANE E DOE, being a resident of Maricopa County, State of Arizona, and an adult of sound and
disposing mind and memory, not acting under duress, menace, fraud or undue influence of any person,
do make, publish and declare this to be my Living Will to supplement all other Wills I may execute.
Unless My ADVANCE HEALTH CARE DIRECTIVE Provides Otherwise For Specific
Instructions Regarding Any Actions and/or Terms Prescribed Herein or That Revokes This
Instrument Entirely, I request that this Living Will be used in the event that I am mentally
incapacitated with a catastrophic/terminal medical condition.
1. Declaration of Intent. I realize that, when I am conscious and functioning normally with full
mental facilities, I have a legal right to accept or reject medical treatment offered to me by doctors,
hospitals or other medical instrumentalities. It is my intent with this Living Will to express my
commitment and to designate persons (personal agents/representatives) who are legally empowered to
act for me when I am unconscious or mentally incapacitated, with full authority from me to make
medical decisions for me and to accept or reject medical treatment offered to me. I rely on the
constitutional law and desire that this Living Will be enforced even if I am in a state of the United States
which has not adopted specific statutes related to the enforcement of Living Wills.
2. Purpose. The purpose of this Living Will is to prevent my remaining assets from being used to
unnecessarily prolong my life, and instead be used to benefit those of my family and/or other heirs who
benefit from my worldly estate. Also, I desire to avoid the heartache extended to my loved ones, which
may be caused by a prolonged illness, and I wish to avoid additional pain and suffering of myself
through whatever senses remain. In the unlikely event that this instrument may not be legally binding in
the jurisdiction where I may be terminally ill, then I trust that you who care for me will feel morally
bound to follow its mandate. It is my decision made after careful consideration.
3. Instruction. If at any time, I should have an incurable injury, disease or illness certified to be a
terminal condition, including what is determined to be a permanent vegetative state or an irreversible
coma, by two (2) physicians who have personally examined me, one of whom is my attending
physician, and the physicians have determined that my death will occur unless life-sustaining
procedures would serve only to artificially prolong the dying process, then I direct that life-sustaining
procedures be withheld or withdrawn. In such case, I direct that I be permitted to die naturally with
only, but not necessarily, the administration of medication or fluids or the performance of medical
procedures deemed necessary to provide me with comfortable care - but not, however, if such
administration and performance prolongs my life unnaturally. NOTWITHSTANDING, in the absence
of my ability to give directions regarding any use, or the termination thereof, of any medication or
fluids, I give sole and unhindered discretion and power to my (appointed) Agents of my Durable Power
of Attorney for Health Care to make the final decision regarding the use, or termination thereof, of any
such hydration or fluids administered to my body. I have made my expression of my legal right to refuse
any treatment offered to me, in such case, and I accept the consequences from such refusal.
4. Mechanics of Implementation. In order to implement this Living Will, the following must
occur: My family physician, along with one other consulting physician, shall make a finding that: I am
unconscious, mentally incompetent or deranged, senile, insane, or otherwise in an abnormal mental
condition where I am not reasonably able to make decisions of my own; or, through an accident, a
disease, a nervous system disorder or otherwise, I have acquired an irreversible condition resulting in (i)
a brain that is dead, (ii) a brain that is damaged to the point where I will not be able to enjoy a
reasonably normal life, (iii) a body with damaged organs or parts that will prevent me from enjoying the
quality of productive life to which I am accustomed or (iv) a combination thereof.
Living Will Page 1 (of 3)

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4.1. Notwithstanding, if my family physician is not available, then two attending physicians
may concur with the consulting physician in the finding. The findings of the physicians will be written
on my patient chart or on a dated piece of paper to be placed in my patient file.
4.2. Thereupon, the representative(s) I have first designated to serve per this Living Will –
i.e., my HEALTH CARE POWER OF ATTORNEY AGENTS – shall concur and evidence that
concurrence on the patient chart or otherwise on the dated paper with the physician's written findings. If
my first designated representative or the next is not readily available, then whichever one is the most
readily available shall sign an affirmation of the decision.
4.3. If my representative is not physically available, then concurrence may be affirmed by (i)
two witnesses over the phone with those witnesses evidencing the consent by writing this in the patient
chart or on the dated paper concerning the physician's written findings or (ii) by telegram or other means
used for transmitting the written language, a copy of which shall be placed in my medical files. The
findings of my doctors and the decision of my representative, once written, shall not be subject to
denunciation by anyone at any later date.
5. Persons Designated To Make Decisions. I now hereby authorize the persons whom I have
appointed as Agents/Attorneys-in-Fact of my Durable Power of Attorney for Health Care, which I
have simultaneously executed with this Living Will, to make the decision conferred upon them by this
instrument. Neither the attending physician nor the hospital is required to determine the reason for
any absence of the agents I have chosen. Whichever one, if any, of my family representatives who
appears is to take the responsibility of making an effort to locate the persons designated with higher
priority. However, I trust any of the persons I have named as my agents to make the necessary
decisions. I know that whoever makes the decisions will have made every effort to notify all the agents
to obtain their concurrence and, if they cannot contact them in time or get concurrence of all parties,
they have the authority to make the necessary decisions. I designate these agents also as my guardians
ad litem and guardians of my person to sign all documents and bring any legal proceeding that may be
necessary to exercise the power and authority vested in them by this Living Will, which includes the
power to bring court proceedings for injunctive relief, damages, or other relief if necessary to carry out
my wishes expressed in this Living Will without court proceedings. However, if any doctor, hospital, or
other medical institution fails to carry out the instructions of my Living Will and the decisions made by
my designated agents herein, then I instruct my agents to carry out my instructions and bring immediate
court proceedings to enforce this Living Will. I direct that this Living Will be implemented by my
designated agents and the attending doctors acting together without the necessity of consulting courts,
administrative bodies or hospital committees.
6. Protection for Persons Designated and Those Assisting. As further evidence of my convictions,
which have been expressed in this Living Will, I direct that the assets of my estate and my insurance be
used to hold harmless from any liability the agents designated and any doctor, hospital or other medical
instrumentality that assists in carrying out my instructions of the persons designated by me to do so,
except those who have acted with gross negligence or willful misconduct.
x________________________________
JANE E DOE
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NOTE: THIS LIVING WILL DECLARATION SHOULD BE SIGNED BY TWO ELIGIBLE WITNESSES AS
DEFINED BELOW WHO ARE NOT BENEFICIARIES OF YOUR ESTATE AND PRESENT WHEN YOU
SIGN THIS DOCUMENT BEFORE A NOTARY PUBLIC.
ACKNOWLEDGEMENT
The Declarant signing the foregoing Living Will Declaration is personally known to us or
has provided proof of her identity, signed or acknowledged her signature on this document in
our presence, appears to be of sound mind and not under duress, fraud or undue influence, has
not appointed either of us as her health care representative, has not named either of us as a
beneficiary of her estate, and is not a patient for whom either of us is an attending physician.
x________________________________ _________________________________
Witness Address
x________________________________ _________________________________
Witness Address
STATE OF ARIZONA
COUNTY OF MARICOPA
instrument and –
_________________________________ & _________________________________
Signature: ___________________________ (Seal)
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