Durable Power Of Attorney For Health Care Decisions Form (Page 2 of 2) in pdf

Durable Power Of Attorney For Health Care Decisions Form Page 2

SUBSTITUTE AGENT

If the person designated above (Agent 1) ceases to act as my agent due to death,

resignation, removal, disability or incapacity (as determined by certification by a licensed physician),

I appoint the following persons in order of priority meaning Agent 2 shall act and if that agent ceases

to act as my agent due to death, resignation, removal, disability or incapacity (as determined by

certification by a licensed physician) then Agent 3 shall act, as my substitute agent with all the same

powers granted to the originally appointed agent.

Agent 2:

Name: _________________________________

Address: _______________________________

City, State: _____________________________

Phone Number: _________________________

Relationship: ___________________________

Agent 3:

Name: _________________________________

Address: _______________________________

City, State: _____________________________

Phone Number: _________________________

Relationship: ___________________________

GUARDIAN

If protective proceedings are commenced on account of my disability or incapacity, I

hereby nominate to the court the above-named agent or substitute agent to be my guardian.

REVOCATION

Any Durable Power of Attorney for Health Care Decisions I have previously made is

hereby revoked. This Durable Power of Attorney for Health Care Decisions shall be revoked by an

instrument in writing signed and acknowledged in the same manner as required herein.

SIGNATURE

Signed this ____ day of _______________, 20__ at ___________________ (insert city, state)

________________________________________

Person Signing Power

STATE OF KANSAS, COUNTY OF SALINE, ss:

The foregoing instrument was acknowledged before me this _________ day of

_____________________, 20____, by ___________________________________________.

(notary stamp)

________________________________________

Notary Public

(Rev. 9/02)

Durable Power of Attorney for Health Care Decisions - Page 2 of 2

Durable Power Of Attorney For Health Care Decisions Form Page 2