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Alam One Stop Tax and Accounting Services

Alam One Stop Tax and Accounting. Services, Inc

3933 Baronet Ct., San Jose, CA 95121

(408)202-0306

Estate Planning Application:

Living Will/ Power of Attorney for Health Care

If you need a Guardian or Conservator, do you name the Agent to be your Guardian or Conservator? *
Select "Yes" if you prefer your Agent to be your guardian or conservator if one is needed. If the Agent is unable to serve, the Alternate Agent will be nominated. Guardians and conservators are actually appointed by a court.
Do you want your life to be prolonged regardless of your condition?
Select "Yes" if you want your life prolonged as long as possible within the limits of general health-care standards. Select "No" if you DO NOT want your life to be prolonged and to give further instructions. NOTE: This provision must be initialed on the printed document.
Do you want to receive food and fluids artificially regardless of your condition?
Select "Yes" if artificially administered nutrition (food) and hydration (fluids) should be provided regardless of your condition and regardless of your choices made in the previous questions. NOTE: This provision must be initialed on the printed document.
If desired, enter any reasons why you would not want to receive treatment to reduce discomfort or pain. Leave this field blank if you always want to receive treatment for pain and discomfort, even if it hastens your death.
Do you want to state any additional wishes or instructions?
Select "Yes" if you want to state additional wishes or instructions.
Enter your additional wishes or instructions. For example, state your preference where you receive your care, your personal values, or special instructions to your agent.
Which organs or tissues do you want to donate at your death, if any?
Select the option that best states which organs, tissues, or body parts you would like to donate upon your death. Such donations are referred to as "anatomical gifts".
How should the donated organs be used?
Select the options that indicate how you want your donation used.
Can your Agent authorize an autopsy and make arrangements for disposal of your remains?
Select "Yes" to give your agent this authority.
Enter the name and address of a physician who you desire to be primarily responsible for your health care.
Who will acknowledge your signature?
Select who will acknowledge your signature. The document must be signed by either two witnesses or a notary public. If you are a patient in a skilled nursing facility, one of the two witnesses must be a patient advocate or ombudsman. This advocate must also sign the document if it is notarized.
Enter the name of the Witness. Review and comply with the witness limitations which appear in the document. You may enter the witness information now or when the document is signed.
Enter the name of the Witness. You may enter the witness information now or when the document is signed.
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