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Five Wishes Document

Signing and Witnesses, reprinted with permission

Page Five of Five Pages — Page One

Please Note: This last page of our reprint of the Five Wishes document concerns how the form must be signed in order for it to be legal in the states noted earlier. Rather than give you all the wording here, since you have to have the paper version for it to be legal, we have only included the following so you can know a little about the steps you will need to take to make the printed form legal.

Residents of Institutions in Connecticut, Delaware, Georgia, New York, and North Dakota Must Follow Special Witnessing Rules

If you live in certain institutions (a nursing home or other licensed long term care facility, a home for the mentally retarded or developmentally disabled, or a mental health institution) in the states of Connecticut, Delaware, Georgia, New York or North Dakota, you may have to follow special "witnessing requirements" for your Five Wishes to be valid. For further information on what you need to do if you live in an institution in one of these five states and want to fill out Five Wishes, please contact a social worker or patient advocate at your institution.

If you live in Connecticut, Delaware, Georgia, New York or North Dakota, and you do not live in an institution, then you can fill out the Five Wishes form just the way it is.

Special Circumstances for Signing the Five Wishes Form

You will need to sign your Five Wishes form in the presence of two witnesses. Make sure they sign their names in your presence. You do not need to have this form notarized unless you live in California, Hawaii, Missouri, or North Carolina.

If you live in California, Hawaii or North Carolina, you should have your signature, and the signatures of your witnesses, notarized. If you live in Missouri, only your signature should be notarized.

Witness Statement

The following is on the Five Wishes form:

I declare that the person who signed or acknowledged this form (hereafter "person") is personally known to me, that he/she signed or acknowledged this [Health Care Agent and/or Living Will form(s)] in my presence, and that he/she appears to be of sound mind and under no duress, fraud, or undue influence.

I also declare that I am over 19 years of age and am NOT:

the individual appointed as (agent/proxy/surrogate/patient advocate) by this document,

the person's health care provider, including owner or operator of a health, long-term care, or other residential or community care facility serving the person,

an employee of the person's health care provider,

financially responsible for the person's health care,

an employee of a life or health insurance provider for the person,

related to the person by blood, marriage, or adoption, and,

to the best of my knowledge, a creditor of the person or entitled to any part of his/her estate under a will or codicil, by operation of law.

Five Notes of Particular Interest

1. Five Wishes is meant to be a helpful resource for you as you talk with your doctor, family and others about how you want to be treated when you are serious ill. Five Wishes does not try to answer all questions about all situations you may come up against. And remember, while the information in this booklet is up-to-date as of the date it was published, laws can change quickly! So if you have a specific question or problem, you should talk to a professional for medical or legal advice.

2. Aging With Dignity is happy to send you Five Wishes free of charge. If you can, they ask that you please send them a check or money order in the amount of four dollars. It will help them reduce their mailing and handling costs.

3. On the form you must send for, there is a card you can fill out and laminate for safekeeping in your wallet. It is an "Important Notice to Medical Personnel: I have a Five Wishes Living Will.".

4. In addition to the printed version of Five Wishes, there is a Five Wishes Video that can be used as a teaching guide. It discusses the importance of advance care planning; gives instruction on completing Five Wishes; tells what to do after you complete Five Wishes so that your wishes are followed; and answers common questions, through a concise 25-minute presentation. The cost is only $19.95.

5. To obtain copies of Five Wishes and the Five Wishes Video, please print and complete the order form [located on the order page of the Aging with Dignity website] and mail or fax it to:

Aging with Dignity

PO Box 1661

Tallahassee, FL 32302-1661

Phone: (850) 681-2010

1-888-5-WISHES (or 1-888-594-7437)

Fax: (850) 681-2481

http://www.agingwithdignity.org

Orders with payment by credit card or purchase order are welcome by fax or mail. Checks may be made payable to Aging with Dignity, and should be mailed along with the order form.On the form you must send for, there is a card you can fill out and laminate for safekeeping in your wallet. It is an "Important Notice to Medical Personnel: I have a Five Wishes Living Will.".

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