Illinois Living Will Declaration Template (Page 5 of 8) in pdf

Illinois Living Will Declaration Template Page 5

(IF YOU WISH TO NAME YOUR AGENT AS GUARDIAN OF YOUR PERSON, IN

THE EVENT A COURT DECIDES THAT ONE SHOULD BE APPOINTED, YOU

MAY, BUT ARE NOT REQUIRED TO, DO SO BY RETAINING THE FOLLOWING

PARAGRAPH.

THE COURT WILL APPOINT YOUR AGENT IF THE COURT

FINDS THAT SUCH APPOINTMENT WILL SERVE YOUR BEST INTERESTS AND

WELFARE. STRIKE OUT PARAGRAPH 6 IF YOU DO NOT WANT YOUR AGENT

TO ACT AS GUARDIAN.)

6. If a guardian of my person is to be appointed, I nominate the agent acting under this

power of attorney as such guardian, to serve without bond or security.

7. I am fully informed as to all the contents of this form and understand the full import of

this grant of powers to my agent.

Signed

(principal)

The principal has had an opportunity to read the above form and has signed the form or

acknowledged is or her signature or mark on the form in my presence.

(witness)

Residing at

(YOU MAY, BUT ARE NOT REQUIRED TO, REQUEST YOUR AGENT AND

SUCCESSOR AGENTS TO PROVIDE SPECIMEN SIGNATURES BELOW. IF YOU

INCLUDE SPECIMEN SIGNATURES IN THIS POWER OF ATTORNEY, YOU

MUST COMPLETE THE CERTIFICATION OPPOSITE THE SIGNATURES OF THE

AGENTS.)

Specimen signature of agent (and successors)

(agent)

I certify that the above signature of my agent is correct.

(principal)

Specimen signature of successor agent

(successor agent)

I certify that the above signature of my successor agent is correct.

(principal)

Specimen signature of successor agent

(successor agent)

I certify that the above signature of my successor agent is correct.

(principal)

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Illinois Living Will Declaration Template Page 5