ÿWPCæ 3Ççªb½ýG•"~™í¿±šb3$´ åøOIÈŸB£VC÷«¢³ÄW|kVŒ'ÏÞrÒês.ÿ2Ų—ÉÏgÒ E9ðifPÁ‰Ð´ýSÍ”@+óÍ¢¸3ÎïùÙÎɱ ”ÓÆOV/G°x÷7(ˆ1pG¸òŒâj¸ÿØA¹7(´hVÍKx QMnå÷—猖È`¿XÙÒ­kÚüÚˆ—[ßy—:ˆNò·ÐØgœ>8uiXv”öué9wMÿgéRT Dx¡¶Á¶ Ä^A®@Ý—%É+õØD®pÊ-‹Uü:œ†z UÑ"n#ÁGˆi±îa™ËÏݘLÓ"ֆȖ«T¢ÔâÑh)Q´¸ÿ{¼èÃ¥Þ£`"æ,@%2ßÀpLV»~ÈÔæÏ!x!Î{?[›©è‚–ðM£é402?¥¡+ãÅtkvT$UÅÕËÒ”0¾ùKÞBõ8þ7ÊÏšˆ©$-äüKß=ÐæÂ¦Å½b®kñ‚ÂV FÈ8äqÀ²…Ì‘«Jª  ÛÇZRa mcåz 0‡_˜Brother MFC-P2000 series,È,,,,,È0(ÖÃ9 Z‹6Times New Roman RegularX(C$¡¡Ô€XxnXXXÔÔ  ÔÔ  ÔÓ  Ó(ÖÃ9 Z ‹6Times New Roman Regular:²û&¬ ¶E·D¸D¹Uº[»[¼[½U¾ÒÅds]ï&ing'N3|xÅÿU‹ÿÀÀÀ ÛÝ ƒ ×f*ÝÔ€X´~XXXÔÔ  ÔÔ  ÔÓ  ÓÝ  ÝÔ_Ôò òòòMEDICAL€POWER€OF€ATTORNEY€AND€DISCLOSURE€STATEMENTà€ö ö E(#àPAGE€Ú  Ú1Ú  Úóóó ó(_3×f$ªªÝ ƒ!ÝÔ€X´~XXXÔÔ  ÔÔ  ÔÓ  ÓÝ  ÝÝ ƒ!ÝÔ€X´~XXXÔÔ  ÔÔ  ÔÓ  ÓÝ  ÝÔ_ÔÔ‡X´~XXX´~ÔÓ  Óòòò òñ¾ñÖ€ ÿÿÖñ¾ññÅñÑ  ÑñÅñINFORMATION€CONCERNINGÐ ° ÐTHE€MEDICAL€POWER€OF€ATTORNEYó óóóÐ È ÐÌÓ  ÓTHIS€IS€AN€IMPORTANT€LEGAL€DOCUMENT.€€BEFORE€SIGNING€THIS€DOCUMENT,€YOUÏSHOULD€KNOW€THESE€IMPORTANT€FACTS:€ÌÌà  àExcept€to€the€extent€you€state€otherwise,€this€document€gives€the€person€you€name€as€yourÏagent€the€authority€to€make€any€and€all€health€care€decisions€for€you€in€accordance€with€your€wishes,Ïincluding€your€religious€and€moral€beliefs,€when€you€are€no€longer€capable€of€making€them€yourself.€ÏBecause€"health€care"€means€any€treatment,€service,€or€procedure€to€maintain,€diagnose,€or€treat€yourÏphysical€or€mental€condition,€your€agent€has€the€power€to€make€a€broad€range€of€health€careÏdecisions€for€you.€€Your€agent€may€consent,€refuse€to€consent,€or€withdraw€consent€to€medicalÏtreatment€and€may€make€decisions€about€withdrawing€or€withholding€life-sustaining€treatment.€€YourÏagent€may€not€consent€to€voluntary€inpatient€mental€health€services,€convulsive€treatment,Ïpsychosurgery,€or€abortion.€€A€physician€must€comply€with€your€agent's€instructions€or€allow€youÏto€be€transferred€to€another€physician.ÌÌà  àYour€agent's€authority€begins€when€your€doctor€certifies€that€you€lack€the€competence€toÏmake€health€care€decisions.ÌÌà  àYour€agent€is€obligated€to€follow€your€instructions€when€making€decisions€on€your€behalf.€ÏUnless€you€state€otherwise,€your€agent€has€the€same€authority€to€make€decisions€about€your€healthÏcare€as€you€would€have€had.ÌÌà  àIt€is€important€that€you€discuss€this€document€with€your€physician€or€other€health€careÏprovider€before€you€sign€it€to€make€sure€that€you€understand€the€nature€and€range€of€decisions€thatÏmay€be€made€on€your€behalf.€€If€you€do€not€have€a€physician,€you€should€talk€with€someone€else€whoÏis€knowledgeable€about€these€issues€and€can€answer€your€questions.€€You€do€not€need€a€lawyer'sÏassistance€to€complete€this€document,€but€if€there€is€anything€in€this€document€that€you€do€notÏunderstand,€you€should€ask€a€lawyer€to€explain€it€to€you.ÌÌà  àThe€person€you€appoint€as€agent€should€be€someone€you€know€and€trust.€€The€person€mustÏbe€18€years€of€age€or€older€or€a€person€under€18€years€of€age€who€has€had€the€disabilities€of€minorityÏremoved.€€If€you€appoint€your€health€or€residential€care€provider€(e.g.,€your€physician€or€an€employeeÏof€a€home€health€agency,€hospital,€nursing€home,€or€residential€care€home,€other€than€a€relative),€thatÏperson€has€to€choose€between€acting€as€your€agent€or€as€your€health€or€residential€care€provider;€theÏlaw€does€not€permit€a€person€to€do€both€at€the€same€time.ÌÌà  àYou€should€inform€the€person€you€appoint€that€you€want€the€person€to€be€your€health€careÏagent.€€You€should€discuss€this€document€with€your€agent€and€your€physician€and€give€each€a€signedÏcopy.€€You€should€indicate€on€the€document€itself€the€people€and€institutions€who€have€signedÏcopies.€€Your€agent€is€not€liable€for€health€care€decisions€made€in€good€faith€on€your€behalf.ÌÌà  àEven€after€you€have€signed€this€document,€you€have€the€right€to€make€health€care€decisionsÏfor€yourself€as€long€as€you€are€able€to€do€so€and€treatment€cannot€be€given€to€you€or€stopped€overÐ ˜-è(,  Ðyour€objection.€€You€have€the€right€to€revoke€the€authority€granted€to€your€agent€by€informing€yourÏagent€or€your€health€or€residential€care€provider€orally€or€in€writing€or€by€your€execution€of€aÏsubsequent€medical€power€of€attorneyò òó ó.€€Unless€you€state€otherwise,€your€appointment€of€a€spouseÐ ˆØ Ðdissolves€on€divorce.ÌÌà  àThis€document€may€not€be€changed€or€modified.€€If€you€want€to€make€changes€in€theÏdocument,€you€must€make€an€entirely€new€one.ÌÌà  àYou€may€wish€to€designate€an€alternate€agent€in€the€event€that€your€agent€is€unwilling,Ïunable,€or€ineligible€to€act€as€your€agent.€€Any€alternate€agent€you€designate€has€the€same€authorityÏto€make€health€care€decisions€for€you.ÌÌTHIS€POWER€OF€ATTORNEY€IS€NOT€VALID€UNLESS€IT€IS€SIGNED€IN€THE€PRESENCEÏOF€TWO€COMPETENT€ADULT€WITNESSES.€€THE€FOLLOWING€PERSONS€MAY€NOT€ACTÏAS€ONE€OF€THE€WITNESSES:ÌÌà  àà ` à(1)the€person€you€have€designated€as€your€agent;ÌÌà  àà ` à(2)a€person€related€to€you€by€blood€or€marriage;ÌÌà  àà ` à(3)a€person€entitled€to€any€part€of€your€estate€after€your€death€under€a€will€or€codicilÏexecuted€by€you€or€by€operation€of€law;ÌÌà  àà ` à(4)your€attending€physician;ÌÌà  àà ` à(5)an€employee€of€your€attending€physician;ÌÌà  àà ` à(6)an€employee€of€a€health€care€facility€in€which€you€are€a€patient€if€the€employeeÏis€providing€direct€patient€care€to€you€or€is€an€officer,€director,€partner,€or€business€office€employeeÏof€the€health€care€facility€or€of€any€parent€organization€of€the€health€care€facility;€orÌÌà  àà ` à(7)a€person€who,€at€the€time€this€power€of€attorney€is€executed,€has€a€claim€againstÏany€part€of€your€estate€after€your€death.Ð  0"€  ÐòòÓ  Óóóòòò òMEDICAL€POWER€OF€ATTORNEYó óóóÐ ° ÐÌÓ  ÓDESIGNATION€OF€HEALTH€CARE€AGENT.ÌÌà  àI,_______________________________(insert€your€name)appoint:ÌÌà0  àName:________________________________________________________Ð (#(# Ðà0  àAddress:_____________________________________________________Ð (#(# Ðà0  àPhone____________________________________________Ð (#(# ÐÌas€my€agent€to€make€any€and€all€health€care€decisions€for€me,€except€to€the€extent€I€state€otherwiseÏin€this€document.€€This€medicalò òó ó€power€of€attorney€takes€effect€if€I€become€unable€to€make€my€ownÐ P  Ðhealth€care€decisions€and€this€fact€is€certified€in€writing€by€my€physician.ÌÌLIMITATIONS€ON€THE€DECISION-MAKING€AUTHORITY€OF€MY€AGENT€ARE€ASÏFOLLOWS:ÌÌÓ  Ó__________________________________________________________Ì_______________________________________________________________ÌÓÛÓÌDESIGNATION€OF€ALTERNATE€AGENT.ÌÌà  à(You€are€not€required€to€designate€an€alternate€agent€but€you€may€do€so.€€An€alternate€agentÏmay€make€the€same€health€care€decisions€as€the€designated€agent€if€the€designated€agent€is€unableÏor€unwilling€to€act€as€your€agent.€€If€the€agent€designated€is€your€spouse,€the€designation€isÏautomatically€revoked€by€law€if€your€marriage€is€dissolved.)ÌÌà  àIf€the€person€designated€as€my€agent€is€unable€or€unwilling€to€make€health€care€decisions€forÏme,€I€designate€the€following€persons€to€serve€as€my€agent€to€make€health€care€decisions€for€me€asÏauthorized€by€this€document,€who€serve€in€the€following€order:ÌÌà  àA.à0 ` àFirst€Alternate€AgentÐp!À` (#` (# ÐÌà0  àà0` (#(#àName:________________________________________€Ð ` (#` (# Ðà0  àà0` (#(#àAddress:_____________________________________Ð ` (#` (# Ðà0  àà0` (#(#àPhone__________________________________Ð ` (#` (# ÐÌà0  àB.à0` (#(#àSecond€Alternate€AgentÐø&H"%` (#` (# ÐÌà0  àà0` (#(#àName:________________________________________€Ð ` (#` (# Ðà0  àà0` (#(#àAddress:_____________________________________Ð ` (#` (# Ðà0  àà0` (#(#àPhone__________________________________Ð ` (#` (# ÐÐ ”+ä&* Ðà  àThe€original€of€this€document€is€kept€at:ÌÌÌÓ  Ó______________________________________________________Ìà @ àà @` à______________________________________________________Ìà @ àà @` à______________________________________________________ÌÓ  ÓThe€following€individuals€or€institutions€have€signed€copies:ÌÌà0  àName:_________________________________________________Ð (#(# Ðà0  àAddress:______________________________________________Ð (#(# Ðà0  àà0` (#(#à______________________________________________________€Ð ` (#` (# ÐÌà0  àName:_________________________________________________Ð (#(# Ðà  àAddress:______________________________________________Ìà0  àà0` (#(#à______________________________________________________€Ð ` (#` (# ÐÌDURATION.ÌÌà  àI€understand€that€this€power€of€attorney€exists€indefinitely€from€the€date€I€execute€thisÏdocument€unless€I€establish€a€shorter€time€or€revoke€the€power€of€attorney.€€If€I€am€unable€to€makeÏhealth€care€decisions€for€myself€when€this€power€of€attorney€expires,€the€authority€I€have€granted€myÏagent€continues€to€exist€until€the€time€I€become€able€to€make€health€care€decisions€for€myself.ÌÌ(IF€APPLICABLE)This€power€of€attorney€ends€on€the€following€date:_____€ÌÌPRIOR€DESIGNATIONS€REVOKED.ÌÌà  àI€revoke€any€prior€medicalò òó ó€power€of€attorneyò òó ó.Ð ”ä ÐÌACKNOWLEDGMENT€OF€DISCLOSURE€STATEMENT.ÌÌà  àI€have€been€provided€with€a€disclosure€statement€explaining€the€effect€of€this€document.€€IÏhave€read€and€understand€that€information€contained€in€the€disclosure€statement.ÌÌà  à(YOU€MUST€DATE€AND€SIGN€THIS€POWER€OF€ATTORNEY.)ÌÌà  àI€sign€my€name€to€this€medicalò òó ó€power€of€attorney€on€___________€day€ofÐ à%0!$ Ð_______________________________________________________(month,€year)€Ïat_________________________________________________________€(City€and€State).Ì_________________________________________________________€€(Signature)Ì_________________________________________________________€€(Print€Name)ÌÓ  ÓÌÓ  ÓSTATEMENT€OF€FIRST€WITNESS.ÌÐ T,¤'+ ÐI€am€not€the€person€appointed€as€agent€by€this€document.€€ò òó ó€I€am€not€ñ»ñòòñ»ñrelated€to€the€principal€by€bloodÐ ° Ðor€marriage.€€I€would€not€be€entitled€to€any€portion€of€the€principal's€estate€on€the€principal's€death.€ÏI€am€not€the€attending€physician€of€the€principal€or€an€employee€of€the€attending€physician.€€I€haveÏno€claim€against€any€portion€of€the€principal's€estate€on€the€principal's€death.€€Furthermore,€if€I€amÏan€employee€of€a€health€care€facility€in€which€the€principal€is€a€patient,€I€am€not€involved€inÏproviding€direct€patient€care€to€the€principal€and€am€not€an€officer,€director,€partner,€or€€businessÏoffice€employee€of€the€health€care€facility€or€of€any€€parent€organization€of€the€health€care€facilityñºñóóñºñ€ñ»ññºñóóñºññ»ñÌÌSignature:____________________________________ÌPrint€Name:______________________Date:__________________ÌAddress:________________________________________________ÌÓ  ÓòòÌñ¼ñóóñ¼ñSIGNATURE€OF€SECOND€WITNESS.ñ¼ñóóñ¼ñÐ À  Ðñ¶ñÌÓ  Ó€€[ò òWitnessó ó]€ñ¶ññ¹ñÌñ¹ñSignature:____________________________________Ìñ·ñ€€ñ·ñPrint€Name:______________________Date:__________________Ìñ¸ñ€€ñ¸ñAddress:________________________________________________ñ½ñÌñ½ñÔ#†X´~XXX´~n#Ô