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Missouri Living Will Declaration Form

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Missouri Living Will Declaration Form

Updated August 03, 2023

A Missouri living will is made by a person (“declarant”) that states they would rather not prolong the dying process if they should be permanently incapacitated. This is often caused by a stroke or other injury that leaves a person with no realistic chance of being cured. Rather than live with breathing and feeding assistance, the declarant chooses to withdraw life-supporting treatments.


How to Write

Download: PDF

Step 1 – Declaration of Declarant/Principal – The Declarant must review the information at the top of the form. If in agreement enter the following:

  • Date the document in dd/mm/yyyy format
  • Printed name of the Declarant
  • Signature of the Declarant
  • Complete physical address of the Declarant

Step 2 – Witnesses – There must be two witnesses to acknowledge the document. Both must read the brief statement. If in agreement, enter the following:

  • Signature of witness
  • Printed name
  • Complete physical address

Step 3 – Revocation Provision – Should the Declarant decide against the living will they have created and are of sound mind, it may revoked at any time by providing the following information:

  • Printed name of Declarant
  • Signature of Declarant
  • Date of signature in mm/dd/yyyy format

Step 4 – Missouri Durable Power of Attorney for Healthcare – Enter the following:

  • Name of Principal/Declarant
  • Complete address of Principal
  • Full name of Attorney in Fact
  • Complete address of Attorney in Fact
  • Home telephone number
  • Work telephone number
  • Name of Alternate Attorney in Fact
  • Complete address of Attorney in Fact
  • Home Phone number
  • Work Phone number

Step 5 – Acknowledgement of Principal – Read the statement. If in agreement:

  • Enter the name of the Principal
  • Date of the document in dd/mm/yyyy format
  • Signature of the Principal

Step 6 – Notarization – Once the notary has witnessed all signatures, they will acknowledge by completing the remainder of the form as required by Missouri law and authenticating with the state seal.

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