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Made by            (name of maker)

of                      (address of maker)


1.            Revocation of previous powers of attorney for personal care

I revoke any previous power(s) of attorney for personal care made by me.

2.            Appointment of attorney

I appoint                (name of attorney) to be my attorney for personal care in accordance with the Substitute Decisions Act, 1992.

3.            Appointment of substitute attorney

If my attorney refuses to act, resigns, dies, becomes mentally incapable of acting, or is removed by court order, I substitute           (name of alternate attorney) as my attorney for personal care in the same manner and subject to the same authority as the person he or she is replacing.

4.            Authority of attorney

I give my attorney the authority to make any personal-care decision for me that I am mentally incapable of making for myself, including the giving or refusing of consent to any matter to which the Health-Care Consent Act, 1996, applies subject to the Substitute Decisions Act, 1992, and any instructions, conditions, or restrictions contained in this form.


5.            Instructions (including end-of-life instructions), conditions, and restrictions (if any)


6.            Signature



(Signature of maker)



(Print name of maker)



(Address of maker)

7.            Witnesses



(Signature of witness)



(Print name of witness)



(Address of witness)




(Signature of witness)



(Print name of witness)



(Address of witness)