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ADVANCE DIRECTIVE

I. APPOINTMENT OF HEALTH CARE AGENT.

I, , born of , , appoint:

as my Agent to make health care decisions for me if I become unable to make such decisions for myself, except to the extent I state otherwise in this document.

NOTICE: An owner, operator, or employee of a health care facility from which the Declarant is receiving health care may not serve as a health care agent unless such person has a close connection with the patient.

1. Appointed as guardian for the patient;

2. The patient's spouse;

3. An adult child of the patient;

4. A parent of the patient;

5. An adult sibling of the patient; or

6. A friend or other relative who is a competent individual, and presents an affidavit to the attending physician stating specific facts and circumstances which demonstrate that the person has maintained regular contact with the patient sufficient to be familiar with the patient's activities, health and personal beliefs.

. STATEMENT OF AUTHORITY GRANTED. Subject to any provisions or limitations in this document, I grant to my agent full power and authority to make health care decisions for me to the same extent that I could make such decisions for myself if I had the capacity to do so, including the power to:

a. Employ and discharge my health care providers;

b. Authorize my admission to or discharge from (including transfer to another facility) any hospital, hospice, nursing home, adult home, or other medical care facility; and

c. Consent to the provision, withholding, or withdrawal of health care, including, in appropriate circumstances, life-sustaining procedures;

d. Ride with me in an ambulance if ever I need to be rushed to the hospital;

e. Be able to visit me if I am in a hospital or any other health care facility.

My agent is to make health care decisions for me based on the health care instructions I give in this document and on my wishes as otherwise known to my agent. If my wishes are unknown or unclear, my agent is to make health care decisions for me in accordance with my best interest, to be determined by my agent after considering the benefits, burdens, and risks that might result from a given treatment or course of treatment, or from the withholding or withdrawal of a treatment or course of action. My agent shall not be liable for the costs of care based solely on this authorization.

. EFFECTIVE. My agent's authority becomes effective

II. TREATMENT PREFERENCES ("LIVING WILL"). (Initial all that apply.)

If I am incapable of making an informed decision regarding my health care, I direct my health care providers to follow my instructions as set forth below.

. TERMINAL CONDITION

If my death from a TERMINAL CONDITION is imminent and even if life-sustaining procedures are used there is no reasonable expectation of my recovery:

. PERSISTENT VEGETATIVE STATE

If my doctors certify that I am in a persistent vegetative state, that is, if I am not conscious and am not aware of myself or my environment or able to interact with others, and there is no reasonable expectation that I will ever regain consciousness:

. END-STAGE CONDITION

If my doctors certify that I am in an end-state condition, that is, an incurable condition that will continue in its course until death and that has already resulted in loss of capacity and complete physical dependency:

. EFFECT OF STATEMENT OF PREFERENCES

III. GENERAL PROVISIONS.

. HOLD HARMLESS. All persons or entities who in good faith endeavor to carry out the terms and provisions of this document shall not be liable to me, my estate, my heirs or assigns for any damages or claims arising because of their action or inaction based on this document, and my estate shall defend and indemnify them.

. SEVERABILITY. If any provision of this document is held to be invalid, such invalidity shall not affect the other provisions which can be given effect without the invalid provision, and to this end the directions in this document are severable.

. STATEMENT OF INTENTIONS. It is my intent that this document be legally binding and effective. If the law does not recognize this document as legally binding and effective, it is my intent that this document be taken as a formal statement of my desire concerning the method by which any health care decisions should be made on my behalf during any period in which I am unable to make such decisions.

(YOU MUST DATE AND SIGN THIS DOCUMENT

IN THE PRESENCE OF TWO WITNESSES)

By signing below, I indicate that I am emotionally and mentally competent to make this Advance Directive and that I understand the purpose and effect of this document. I also understand that this document replaces any similar advance directive I may have completed before this date.

Signed on _____ day of _______________, _____.

STATEMENT OF WITNESSES

signed or acknowledged signing this Advance Directive in my presence and based upon my personal observation appears to be a competent individual. I am not the person appointed as the Health Care Agent or Alternate Health Care Agent by this document. I further declare that to the best of my knowledge, I am not entitled to any portion of the estate of or entitled to any financial benefit by reason of the death of .

Date: _________________________

Date: _________________________