Fillable Living Will Form Tennessee (Page 3 of 4) in pdf

Tennessee Durable Power of Attorney for Healthcare

1. I, ___________________________________________________________________,

(name of principal)

of ____________________________________________________________________,

(address)

state and affirm that I have read the foregoing paragraphs concerning the legal consequences of my executing this document, and I do

hereby appoint:

_______________________________________________________________________

(name of attorney-in-fact)

of _____________________________________________________________________

(address and telephone of attorney-in-fact)

as my attorney-in-fact to have the authority hereinafter set forth in order to express and carry out my specific and general instructions

and desires with respect to medical treatment.

2) In the event the person I appoint above is unable, unwilling or unavailable to act as my healthcare agent, I hereby appoint:

_______________________________________________________________________

(name of alternate attorney-in-fact)

of _____________________________________________________________________.

(address and telephone of alternate attorney-in-fact)

3) I have discussed my wishes with my attorney-in-fact and my alternate attorney-in-fact, and authorize him/her to make all and any

healthcare decisions (as defined by Tennessee law) for me, including decisions to withhold or withdraw any form of life support. I

expressly authorize my agent (and alternate agent) to make decisions for me about tube feeding and medication.

4) This power of attorney becomes effective when I can no longer make my own medical decisions and shall not be affected by my

subsequent disability or incompetence. The determination of whether I can make my own medical decisions is to be made by my

attorney-in-fact, or if he or she is unable, unwilling or unavailable to act, by my alternate attorney-in-fact.

IN WITNESS WHEREOF, I have set my hand this _____ day of ____________, 20____.

_____________________________________

(signature of principal)

I declare under penalty of perjury under the laws of Tennessee that the person who signed this document is personally known to me

to be the principal; that the principal signed this durable power of attorney in my presence; that the principal appears to be of sound

mind and under no duress, fraud or undue influence; that I am not the person appointed as attorney-in-fact by this document; that I am

not a healthcare provider, an employee of a healthcare provider, the operator of a healthcare institution nor an employee of an operator

of a healthcare institution; that I am not related to the principal by blood, marriage, or adoption; that, to the best of my knowledge, I

do not at the present time, have a claim against any portion of the estate of the principal upon his death; and, that, to the best of my

knowledge, I am not entitled to any part of the estate of the principal upon the death of the principal under a will or codicil thereto now

existing, or by operation of law.

First witness’ signature: ___________________________________________________

Printed name: ___________________________________________________________

Address: _______________________________________________________________

_______________________________________________________________

Living Will Form Tennessee Page 3