Living Will Form Page 8
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108
DESIGNATION OF A CONSERVATOR OF THE PERSON
If a conservator of my person should need to be appointed, I designate ________________________, be appointed my
conservator. If _________________________ is unwilling or unable to serve as my conservator, I designate
____________________________. No bond shall be required of either of them in any jurisdiction.
These requests, appointments, and designations are made after careful reflection, while I am of sound mind. Any party
receiving a duly executed copy or facsimile of this document may rely upon it unless such party has received actual notice of
my revocation of it.
Date _______________, 200____
x__________________________________L.S.
STATE OF CONNECTICUT
)
:
ss. _________________________________
COUNTY OF __________________________
)
(Town)
Personally appeared ____________________________, signer of the foregoing instrument, and
acknowledged the same to be his/her free act and deed, before me, this _________ day of
_________________________, 200____.
_____________________________
Commissioner of the Superior Court
Notary Public
My Commission expires: _________
WITNESSES' STATEMENTS
This document was signed in our presence by _____________________________ the author of this document, who appeared
to be eighteen years of age or older, of sound mind and able to understand the nature and consequences of health care
decisions at the time this document was signed. The author appeared to be under no improper influence. We have subscribed
this document in the author's presence and at the author's request and in the presence of each other.
x__________________________
x___________________________
(Witness)
(Witness)
x__________________________
x___________________________
(Number and Street)
(Number and Street)
x__________________________
x___________________________
(City, State and Zip Code)
(City, State and Zip Code)
THIS IS A SAMPLE AND OFFERED SOLELY FOR THE ASSISTANCE OF ATTORNEYS WHO WILL BE RESPONSIBLE FOR THE
ULTIMATE SUBSTANCE AND WORDING OF THE DOCUMENT. THE USE OF THIS SAMPLE BY PARTIES OTHER THAN ATTORNEYS
IS NOT AUTHORIZED
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