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Made by            

of                           , Quebec.

1.            Appointment of personal mandatary

I appoint                of

              , Quebec,

as mandatary of my person pursuant to the Civil Code of Quebec.

2.            Substitute mandatary

If my mandatary is unable or unwilling to act for any reason, then I appoint              

             of               ,

Quebec, as substitute mandatary of my person in his or her place.

3.            Coming into force

This mandate only comes into force when it is homologated by order of the appropriate Court. 

4.            Authority and duties of personal mandatary

a)      General matters

i.    My personal mandatary shall have sole power and authority to make all decisions necessary to ensure my personal protection and to provide for my mental and physical well-being without limitation.

ii.    When acting, I direct my mandatary to respect my values and beliefs, my ability to make decisions for myself, and the standard of living I enjoyed before becoming incapacitated.

iii.   I also expect my mandatary to play as active a role in my life as circumstances permit.

b)      Consent to treatment

If I am unable or refuse to consent to treatment required by my state of health, I give my mandatary power to do so on my behalf. He or she must make an informed decision based on the risks and benefits of the treatment in question.


(initials of mandator and witnesses)

c)     Access to records 

I give my mandatary authority to consult any records dealing with my person, including medical and social records.

d)     Duty to report

I direct my mandatary to file a report of his or her activities once each year on the anniversary of the date he or she began to act with the following person:


5.         My instructions on end-of-life treatments     

(Insert clause from Sample 1.)

6.            General provisions

a)       This mandate revokes any personal mandate previously granted by me.

b)   If a competent tribunal determines that any term of this mandate is invalid, that term shall be severed from this mandate and the rest of this mandate shall continue in full force and effect.

c)   My mandatary shall be reimbursed out of my estate for all reasonable expenses incurred in carrying out this mandate.

d)   If I regain capacity, my mandatary must begin proceedings to revoke this mandate as soon as possible.



Whereof I, the mandator, have signed this personal mandate at                           ,

Quebec, on the                            day of                           , 20                          , before the two undersigned witnesses:





(Signature of mandator)



(Print name of mandator)

(initials of witnesses)                           



We, the undersigned                            (name of witness)

and                            (name of witness)


Solemnly declare that:


1.   We both witnessed the signature of the mandator on the attached mandate.


2.   The mandator was fully capable of acting as mandator.


3.   We have no interest in this mandate.


In witness whereof, we signed this mandate at                           (place of signing)

this                    day of                           , 20                          , in the presence of

                          (name of mandator).





(Signature of witness)                        (Signature of witness)



(Print name of witness)                        (Print name of witness)



(Address)                        (Address)



(Phone number)                        (Phone number)