Form 5625 - Illinois Statutory Short Form Power Of Attorney For Health Care Page 2
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2I want my life to be prolonged to the greatest extent possible without regard to my condition, the chances I have for recovery or the cost of the
procedures.
Initialed _______________________________
(THIS POWER OF ATTORNEY MAY BE AMENDED OR REVOKED BY YOU AT ANY TIME AND IN ANY MANNER WHILE YOU HAVE THE
CAPACITY TO DO SO. ABSENT AMENDMENT OR REVOCATION, THE AUTHORITY GRANTED IN THIS POWER OF ATTORNEY WILL
BECOME EFFECTIVE AT THE TIME THIS POWER IS SIGNED AND WILL CONTINUE UNTIL YOUR DEATH, AND BEYOND IF ANATOMICAL
GIFT, AUTOPSY OR DISPOSITION OF REMAINS IS AUTHORIZED, UNLESS A LIMITATION ON THE BEGINNING DATE OR DURATION IS
MADE BY INITIALING AND COMPLETING EITHER OR BOTH OF THE FOLLOWING:)
3. ( ) This power of attorney shall become effective on
_____________________________________________________________________________________________________
(insert a future date or event during your lifetime, such as court determination of your disability, when you want this power to first take effect)
4. ( ) This power of attorney shall terminate on
_____________________________________________________________________________________________________
(insert a future date or event, such as court determination of your disability, when you want this power to terminate prior to your death.)
(IF YOU WISH TO NAME SUCCESSOR AGENTS, INSERT THE NAMES AND ADDRESSES OF SUCH SUCCESSORS IN THE FOLLOWING
PARAGRAPH.)
5. If any agent named by me shall die, become legally disabled, resign, refuse to act or be unavailable, I name the following (each
to act alone and successively, in the order named) as successors to such agent:
_____________________________________________________________________________________________________
(IF YOU WISH TO NAME A 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 INSERTING THE NAME OF SUCH GUARDIAN IN THE FOLLOWING PARAGRAPH. THE
COURT WILL APPOINT THE PERSON NOMINATED BY YOU IF THE COURT FINDS THAT SUCH APPOINTMENT WILL SERVE YOUR
BEST INTERESTS AND WELFARE. YOU MAY, BUT ARE NOT REQUIRED TO, NOMINATE AS YOUR GUARDIAN THE SAME PERSON
NAMED IN THIS FORM AS YOUR AGENT.)
6. If a guardian of my person is to be appointed, I nominate the following to serve as such guardian:
_____________________________________________________________________________________________________
(insert name and address of nominated guardian of the person)
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 his or her signature or mark
on the form in my presence.
____________________________________ Residing at _________________________________________________________
(witness)
(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 signatures of agent (and successors).
I certify that the signatures of my agent (and successors) are correct.
_____________________________________________
_____________________________________________
(agent)
(principal)
_____________________________________________
_____________________________________________
(successor agent)
(principal)
#5625 (R 01/00)
(2 of 2)
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