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                        **                 ** 
                        **     WARNING     ** 
                        **                 ** 
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                       TO ANY PERSON EXECUTING 
                     A DURABLE POWER OF ATTORNEY 
 
 
 
THIS IS NOT A TRIVIAL MATTER.  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: 
 
1. This document gives the person you designate as your
attorney-in-fact the 
power to make health care decisions for you, subject to any
limitations or 
statement of your demands that you include in this document.  The
power to 
make health care decisions for you may include consent, refusal of
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. 
 
2. The person you designate in this document has a duty to act
consistently 
with your demands as stated in this document or otherwise made
known or, if 
your demands are unknown, to act in your best interests. 
 
3. Except as you other wise specify in this document, the power of
the person 
you designate to make health care decisions for you may include the
power to 
consent to your doctor not giving treatment or stopping treatment
which would 
keep you alive. 
 
4. Unless you specify a shorter period in this document, this power
will 
exist for Seven Years from the date you execute this document and,
if you 
are unable to make health care decisions for yourself at the time
when this 
seven-year period ends, this power will continue to exist until the
time when 
you become able to make health care decisions for yourself. 
 
5. Notwithstanding this document, you have the right to make
medical and 
other health care decisions for yourself so long as you can give
informed 
consent with respect to the particular decision.  In addition, no
treatment 
may be given to you over your objection, and health care necessary
to keep 
you alive may not be stopped if you object. 
 
6. You have the right to revoke the designation of the person named
in this 
document by notifying that person of the revocation orally or in
writing. 
 
7. 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. 
 
8. 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. 
 
9. If there is anything in this document that you do not
understand, you 
should ask a lawyer to explain it to you.  This power of attorney
will not 
be valid for making health care decisions unless it is either (1)
signed by 
two qualified witnesses who are personally known to you and who are
present 
when you sign or acknowledge your signature or (2) acknowledged
before a 
notary public in California. 
 
                      A DURABLE POWER OF ATTORNEY 
                            FOR HEALTH CARE 
 
 
To my family, relatives, my friends, my physicians, health care
providers, 
community care facilities, and any other person who may have an
interest or 
duty: 
 
I, (name), of (address), City of (city), County of (county), State
of 
(state), being of sound mind, freely, willfully, and voluntarily
hereby 
appoint (name of person), of (address), City of (city), County of
(county), 
State of (state), as my attorney-in-fact/proxy to make health care
decisions 
in my stead and behalf.  He/she is not a treating health care
provider nor 
an employee of such, nor is he/she an operator of a community
health care 
facility which is treating me, or an employee of such, nor is
he/she 
conservator of my person or estate; and I hereby request that
he/she never 
be appointed such a conservator. 
 
In the event that (name) is unable or unwilling to serve at my
attorney-in- 
fact for the purpose of making health care decisions for me, I
designate 
(name of alternate) of (address), City of (city), County of
(county), State 
of (state), to serve as my attorney-in-fact. 
 
At any time that I should for any reason be unable to make such
decisions 
for myself, I hereby authorize (name) my attorney-in-fact, to make
any 
decisions I otherwise could make involving consent, refusal of
consent, or 
withdrawal of consent to any care, treatment, service, or procedure
to 
maintain, diagnose, or treat me for any physical or mental
condition 
whatever, except for commitment to or placement in a mental health
treatment 
facility, convulsive treatment, psychosurgery, sterilization, or
abortion. 
 
This appointment shall have no legal force or effect after
expiration of 
seven years from the date of its execution.  It shall have no
effect if I 
revoke it by giving notice of such revocation either orally or in
writing. 
 
This document revokes any prior Durable Power of Attorney for
Health Care. 
 
                   SPECIAL PROVISIONS AND LIMITATIONS 
 
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If there is any type of treatment or placement that you do not want
your 
attorney-in-fact to consent to or other restrictions you want to
place on 
his/her authority, you should list them in the space below.  If you
do not 
write in any limitations, your attorney-in-fact will have the broad
powers 
to make health care decisions on your behalf which are included
above. 
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********** 
 
In exercising authority under this Durable Power of Attorney, the
authority 
of my attorney-in-fact is limited as stated below: 
 
_________________________________________________________________
_____ 
 
_________________________________________________________________
_____ 
 
_________________________________________________________________
_____ 
 
_________________________________________________________________
_____ 
 
                           STATEMENT OF DEMANDS 
 
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Your attorney-in-fact must make decisions consistent with your
known demands.  
You may, BUT ARE NOT REQUIRED TO, indicate your demands below.  If
your 
demands are unknown, he/she must act in your best interests.  A
judicial 
proceeding may be necessary to determine what is in your best
interests.  To 
reduce the risk of the need for court proceedings, you may want to
initial 
the statement or statements below that reflect your demands and/or
write your 
own statements in the space below. 
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********** 
 
1.  I desire that my life be prolonged to the greatest extent
possible, 
    without regard to my condition, the chances I have for recovery
or 
    long term survival, or the cost of the procedures. 
 
                                                 ( Yes _____  No
_____ ) 
 
2.  If I am in a coma, which my doctors have reasonably concluded
is 
    irreversible, I demand that life-sustaining or prolonging
treatments 
    or procedures NOT be used. 
                                                 ( Yes _____  No
_____ ) 
 
3.  If I have an incurable or terminal condition or illness and no

    reasonable hope of long term recovery or survival, I demand
that 
    life sustaining or prolonging treatments NOT be used. 
 
                                                 ( Yes _____  No
_____ ) 
 
4.  If deciding any questions under this document, my
attorney-in-fact is 
    to consider the relief of suffering, the preservation or
restoration 
    of functioning, and the quality as well the possible extension
of my 
    life. 
                                                 ( Yes _____  No
_____ ) 
 
 
                OTHER OR ADDITIONAL STATEMENTS OF DEMANDS 
 
_________________________________________________________________
_____ 
 
_________________________________________________________________
_____ 
 
_________________________________________________________________
_____ 
 
_________________________________________________________________
_____ 
 
_________________________________________________________________
_____ 
 
 
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BEFORE SIGNING THIS DOCUMENT, YOU MUST READ THE "WARNING" THAT
PRECEDES IT.  
IT IS PRINTED IN FULL AT THE START OF THIS DOCUMENT. 
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*********** 
 
 
______________________________     ____________________ 
(Name)                             Date 
 
                           WITNESS SIGNATURES 
 
Under penalty of perjury under the laws of (state), I hereby
declare that 
the principal who signed or acknowledged this Durable Power of
Attorney for 
Health Care Decisions in my presence is known to me personally;
that he/she 
appears to be of sound mind and to be under no duress, fraud, or
undue 
influence; that I am not the person designated as attorney-in-fact
by this 
document; that I am not a health care provider, an employee of a
health care 
provider, the operator of a community care facility, nor an
employee of a 
community care facility.  I am not related to the principal by
blood, 
marriage, or adoption; and to the best of my knowledge, I am not
entitled to 
any part of the estate of the principal upon his/her death either
under a 
will now existing, by a revocable living trust now existing, nor
by operation 
of law. 
 
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*********** 
Under California law, only one witness is required to sign this
document.  
However, it is advisable that two witnesses sign it. 
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*********** 
 
 
______________________________     ______________________________

Witness One                        Date 
 
 
______________________________     ______________________________

Witness Two                        Date 
 
 
 
                         SPECIAL REQUIREMENTS 
 
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For patients in a skilled nursing facility in the state of
California. 
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************ 
 
The principal is a patient in a skilled nursing facility in
California as 
defined in subdivision (c) of Section 1250 of the Health and Safety
Code of 
California at the time he/she executed this document.  Therefore,
and in 
order to make it legally effective in California (or other state),
I, (full 
legal name of witness), ("a patient-advocate" or "an ombudsman")
as 
designated by the State Department of Aging or other duly
authorized person, 
am serving as a witness pursuant to Section 2432 (f) of the
California Civil 
Code. 
 
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********* 
If not a resident of California, strike out either term
"patient-advocate" 
or "ombudsman" or enter an appropriate alternative term. 
Additionally alter 
the previous paragraph as necessary.  Although any other state may
have no 
such requirement, it can do no harm to take the precaution of
having the 
additional witness described in the previous paragraph. 
*****************************************************************
********* 
 
I declare under the penalty of perjury under the laws of California
that I 
am not the person designated as attorney-in-fact/proxy by this
document; that 
I am not a health care provider, an employee of a health care
provider, the 
operator of a community care facility, nor an employee of a
community care 
facility; that I am not related to the principal by blood,
marriage, or 
adoption; and to the best of my knowledge I am not entitled to any
part of 
the estate of the principal under a will now existing, a revocable
living 
trust now existing, nor by operation of law. 
 
 
______________________________     ______________________________

Witness                            Date 
 
 
 
Sworn to and subscribed before me this (day) day of (month),
19(year). 
 
 
My commission expires:          _________________________ 
                                Notary Public 
 
_________________________ 
Date 
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