Indiana Living Will Form | Declaration (Form 55316)

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Updated September 01, 2022

An Indiana living will declaration, or “Form 55316,” establishes a person’s intent to withhold life-sustaining procedures. This would only come into effect when a person has an incurable injury, disease, or illness. It’s recommended to also complete a Medical Power of Attorney to elect an agent to carry out the wises located in this declaration.

Life-Prolonging Procedures (Form 55315) – Use for a person who wishes to extend their life as long as possible.


How to Write

Download: Adobe PDF, MS Word (.docx), OpenDocument

Step 1 – Declaration – Download the form and begin by entering:

  • Date of the declaration in dd/mm/yyyy format

Step 2 – Declarant/Principal Review of Statement – The Declarant must carefully review the statements provided on the form. If the Declarant understands and is in agreement, provide a response to the statement, by initialing the appropriate lines preceding each statement (if any)

Step 3 – Declarant/Principal Signature – The Declarant must read the final paragraph of this section. If in agreement, the Declarant will enter the following:

  • The Declarant’s Signature
  • Enter the Declarant’s City, County and State of Residence

Step 4 – Witness Signatures – This document will require the review and signatures of two (2) witnesses. The witnesses must carefully read the information in this section. If in agreement, the witnesses must enter the following into the form:

Witness 1 –

  • Witness’s Signature
  • Date the signature in mm/dd/yyyy format

Witness 2 –

  • Witness’s Signature
  • Date the signature in mm/dd/yyyy format