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Illinois Durable Power of Attorney Form for Health Care

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Illinois Durable Power of Attorney Form for Health Care should be created when you wish to appoint a reliable friend or relative as an agent to make health care decisions on your behalf. This is considered a precaution in case you are ever in a situation where you can’t make the decisions yourself. This form is based on the provisions set forth in 755 ILCS 45/4-1. Many consider it important to have a form such as this in place in the event that you are in a car accident or have scheduled surgery.

Laws755 ILCS 45/Art. IV

Living Will Declaration – In addition to having an agent make decisions on your behalf, fill-in a living will to make decisions if you want to request not having life-sustaining treatments if in a vegetative state.

Durable (Financial) Power of Attorney – Provides the Principle with the opportunity to choose a friend or relative to make financial decisions on their behalf either indefinitely or for a pre-determined period of time.

How to Write

1 – The Required Form Should Be Opened Or Downloaded From This Page

There will be a preview image on the right of this page. Use the button below this image to open this form. You may enter the information directly on-screen or you may print it then fill it out manually.

2 – The Principal Must Review The Opening Paragraphs

The first two pages of this form will provide some valuable information to the Principal that must be read by the Principal. At the end of these statements will be a blank line where the Principal should place his or her initials to signify comprehension and acknowledgment.

3 – Positively Identify Both The Principal And The Agent

The first set of blank lines below the title have been provided so the Full Name of the Principal may be properly displayed. This report should include the Address of the Principal as it appears on his or her Identification. The Principal will be the individual who will grant another individual (known as “Agent”) the Power to make decisions regarding his or her Health Care/Medical Treatment during a specific time period or upon a Medical Event.

The next set of blank lines have been supplied so the Full Name of the Agent (or Attorney-in-Fact) will be clearly presented. This report must contain the Address of the Agent as it appears on his or her I.D.’s.

2 – The Powers The Agent Will Assume Should Be Presented

The next paragraphs will outline some of the basic Powers the Agent will have but, this will need some definition in terms of the Principal’s wishes regarding Anatomical Gifts. Locate the words “B. Effective upon my death…” Three definitions will be provided to deliver Principal preferences. If none are selected, it will be assumed the Agent may not make Anatomical Gifts on behalf of the Principal.

If the Agent may donate any of the Principal’s Organs, Tissues, or Body Parts, the Principal should initial the statement starting with “Any organs…”

If the Principal will only let the Agent decide upon donating specific organs, then he or she should initial the “Specific Organs” line, then enter the organs the Agent may decide to donate.

If the Principal does not wish to allow the Agent to make any Anatomical Donations, then he or she should initial the blank line labeled “I do not grant…”

There will be several paragraphs that outline the lawful powers given by virtue of this document’s proper execution. The Principal may restrict or extend any of the powers (so long as it is legal) in a manner that he or she deems appropriate in Item 2. There will be several blank lines provided for this purpose, however, if the report on Principal Preferences and/or Instructions requires more room, you may continue the report on an attachment (make sure to cite such an attachment here). There will also be several additional paragraphs to conveniently cover what Principal Preferences are in three specific scenarios. The Principal should initial the ones that apply and leave the ones that do not apply blank.

If the Principal does not wish his or her life prolonged when the treatment outweighs the benefits, then he or she should initial the first paragraph. If the Principal does want his or her life prolonged or life-sustaining treatment unless he or she is in a coma or a permanent state of unconsciousness, then he or she should initial the second paragraph.

If the Principal wishes his or her life prolonged regardless of the circumstances, he or she should initial the third statement. The third item will require the Date or Event that will begin the Agent’s Period of Effective Principal Power. Below this will be an area where you may define what Date or Event will signify the Termination of the Powers designated through this document. If there is a Date of Termination or Event of Termination it should be reported in the fourth item. The next item requiring attention will not seek to define Powers but will seek to define an entity. Item 5 will give the Principal an opportunity to choose a Successive Agent to take up the Principal Power the original Agent named above will wield should he or she be unable to do so. The Principal may name more than one Successor Agent in the order he or she wishes them to assume Power. Make sure each Successor Agent’s Full Name and Complete Address are reported accurately on the blank lines provided here. If the Principal wishes to Name the Agent in this document as his or her Guardian of Estate (should the courts decide it is necessary), the Sixth Item may be left unmarked. If the Principal does not wish to nominate this entity as his or her Guardian, the Principal should strike out the paragraph in this item.

3 – The Principal, Witnesses, And Notary Must Combine Efforts To Execute This Document

The Seventh Item will require the Principal’s Signature Date and the Principal’s Signature on the two blank lines provided. The next item to be attended to will be for the individual bearing witness to the Principal signing this document. In the paragraph labeled “Witness Statement,” there will be enough room for Witness to Sign and Print his or her Name and enter his or her Address.

This document will need to be notarized, so the section below the Witness Statement has been developed for this purpose. Only the Notary Public may fill in the area between the words “State of” and “My Commission Expires.”Next, the Specimen Signature of the Agent and each Successor Agent in this document should be provided in the column on the left, below the words “Specimen Signatures Of Agent (and Successors).” Each Signature must be witnessed by the Principal. The Principal must sign the blank space next to each Signature to substantiate the Agent Signature.

Finally, the Preparer of this paperwork should self-report his or her Full Name, Address, and Telephone Number on the blank lines on Page 10. This section does not need to be filled out if the Preparer is the Principal.