File #
State of California
Secretary of State
Registration of
Written Advance Health Care Directive
(Probate Code sections 4800-4805)
.
Important - Read all instructions before completing this form
This Space For Filing Use Only
1.
Check the applicable box (Note: Check only one box)
New Registration
For a new registration, check this box and complete the entire form. There is a $10.00 fee for
registration of a new directive.
Amendment
For an amendment to a previously filed registration form (not the directive), check this box,
complete Items 3 and 7 and the appropriate section that changed. There is no filing fee.
Revocation Only
For a revocation (change) of a written advance health care directive that has been registered
previously with the Secretary of State or a revocation of your registration, check this box and
complete Items 3 and 7. There is no filing fee.
For a revocation (change) of a written advance health care directive that has been registered
Revocation (change)
of Prior Directive and
previously and the registration of a new directive, check this box and complete the entire form.
New Registration
There is a $10.00 fee for registering the new directive.
2.
Check the applicable statement(s):
The written advance health care directive
This serves as notification of intended place of deposit or safekeeping
is attached.
of a written advance health care directive.
3.
Registrant’s information:
Name (Last)
(First)
(Middle)
Street Address
City and State
Zip Code
Date of Birth
Place of Birth
Enter at least one item:
a. Social Security Number
b. Driver’s License Number and State or Country Issuing
c. Other Identifying Number Established By Law and State or
Country Issuing
4.
Agent information (if any):
Name (Last)
(First)
(Middle)
Home Telephone Number
Work Telephone Number
Mobile Phone Number
(
)
(
)
(
)
5.
Alternate agent information (if any):
Name (Last)
(First)
(Middle)
Home Telephone Number
Work Telephone Number
Mobile Phone Number
(
)
(
)
(
)
6.
Intended place of deposit or safekeeping of the written advance health care directive (if applicable):
7.
Signature of Registrant
Date
Typed or Printed Name of Registrant
SFL 461 (Rev 01/13)