Download 5 Wishes Document Template

The Five Wishes document is a legal form that allows individuals to express their preferences regarding medical treatment and personal care in the event they become seriously ill. This form addresses not only medical decisions but also emotional and spiritual needs, empowering individuals to choose a trusted person to make healthcare decisions on their behalf. By completing this straightforward document, individuals can ensure their wishes are known and respected, providing peace of mind for themselves and their loved ones.

To take control of your healthcare decisions, fill out the Five Wishes document by clicking the button below.

Access Your Document

Access Your Document

Jump Links

Misconceptions

Here are five common misconceptions about the Five Wishes document, along with explanations to clarify each one:

Five Wishes is only for older adults. Many people believe that this document is only necessary for seniors. In reality, anyone aged 18 or older can benefit from it. Accidents and unexpected illnesses can happen at any age, making it important for everyone to have their wishes documented.
Five Wishes is legally binding in every state. Some think that this document is universally accepted. While Five Wishes is valid in many states, it does not meet legal requirements in all of them. It's essential to check your state's laws to ensure it is recognized.
Completing Five Wishes means I have to give up control over my health decisions. This is a common fear. However, Five Wishes allows you to specify your preferences and designate someone to make decisions on your behalf only if you are unable to do so. Until that time, you retain full control.
Once I fill out Five Wishes, I can never change it. Many people think that the document is set in stone. In fact, you can change your Five Wishes whenever you want. Simply fill out a new form and follow the necessary steps to revoke the previous one.
Five Wishes is just a medical form and doesn't address emotional or spiritual needs. Some believe that it only covers medical treatment preferences. However, Five Wishes is unique because it also addresses personal, emotional, and spiritual wishes, making it a comprehensive guide for your loved ones.

File Details

Fact Name	Description
Purpose	The Five Wishes document allows individuals to outline their preferences for medical treatment and care in the event they become unable to communicate their wishes.
Living Will	Five Wishes is recognized as the first living will that addresses not only medical decisions but also personal, emotional, and spiritual needs.
Eligibility	Anyone aged 18 or older can complete the Five Wishes document, regardless of marital status or family situation.
States of Validity	Five Wishes is valid in the District of Columbia and 42 states, including Alaska, Florida, and California, among others.
Legal Support	This document was developed with input from the American Bar Association, ensuring it meets legal standards in many jurisdictions.
Ease of Use	The form is designed to be simple, allowing individuals to express their wishes by checking boxes or writing brief statements.
Revocation Process	To revoke a previous directive, individuals must destroy old copies of their living wills and inform relevant parties, including their healthcare agent.
Widespread Adoption	Over 19 million people have utilized the Five Wishes document, making it a widely accepted tool for advance care planning.

Key takeaways

Filling out the Five Wishes document is a significant step in ensuring that your healthcare preferences are respected. Here are key takeaways to keep in mind:

Understand the Purpose: Five Wishes is more than just a living will. It allows you to express your personal, emotional, and spiritual needs alongside your medical wishes.
Choose Your Advocate Wisely: Select a health care agent who knows you well and can make decisions in your best interest. This person should be someone you trust, ideally over the age of 18, and not someone who might have conflicting interests.
Communicate Your Wishes: After completing the document, discuss your wishes with family and your chosen health care agent. This conversation can alleviate their burden during difficult times and ensure they understand your preferences.
Keep It Updated: If you change your mind about your health care agent or any other aspect of your wishes, make sure to revoke the previous document and inform your family and healthcare providers of the changes.

Dos and Don'ts

When filling out the Five Wishes Document form, there are several important guidelines to follow. Here’s a helpful list of things you should and shouldn’t do:

Do read the entire document carefully before filling it out to understand its purpose and implications.
Do choose a health care agent who knows you well and can make decisions that align with your wishes.
Do discuss your wishes with your chosen agent and family members to ensure everyone is on the same page.
Do sign and date the form in the presence of a witness, if required, to ensure its validity.
Don't leave any sections blank; make sure to fill out all required information completely.
Don't choose someone who may have conflicts of interest, like your health care provider or their employees.

By following these guidelines, you can ensure that your Five Wishes Document is filled out correctly and reflects your personal preferences regarding health care decisions.

Common mistakes

Incomplete Information: Many individuals forget to fill in all required fields. This includes personal details such as name and birthdate. Omitting this information can render the document invalid.
Choosing the Wrong Health Care Agent: Selecting someone who may not be able to fulfill the role is a common mistake. It is important to choose someone who understands your wishes and can advocate for you when necessary.
Not Communicating Wishes: Failing to discuss your preferences with your chosen agent and family members can lead to confusion. Open conversations about your desires are essential to ensure your wishes are honored.
Ignoring State Requirements: Each state has different legal requirements for advance directives. Not being aware of these can result in the document not being recognized. Always check if your state accepts the Five Wishes document.
Neglecting to Update the Document: Life circumstances change, and so might your preferences. Forgetting to update the Five Wishes document after significant life events can lead to misalignment between your current wishes and what is documented.

What You Should Know About This Form

What is the Five Wishes document?

The Five Wishes document is a unique living will that allows you to express not just your medical preferences, but also your personal, emotional, and spiritual needs. It gives you the power to choose someone to make health care decisions for you if you can’t make them yourself. This document aims to ensure that your wishes are known and respected during serious illness.
Who can use the Five Wishes document?

Anyone aged 18 or older can use the Five Wishes document. This includes married individuals, singles, parents, adult children, and friends. Over 19 million people have already completed it, and it is widely accepted by various organizations, including hospitals and legal professionals.
How do I complete the Five Wishes document?

Completing the Five Wishes document is straightforward. You simply fill out the form by checking boxes, circling options, or writing brief sentences. Once you’ve filled it out, sign it according to the instructions. Make sure to share your completed document with your chosen health care agent and family members to ensure they understand your wishes.
Can I change my Five Wishes document?

Yes, you can change your Five Wishes document at any time. If you decide to use a new version, make sure to destroy all copies of the old document. Inform your health care agent and family about the changes, and if necessary, write "revoked" on the old copies to avoid confusion.
Is the Five Wishes document legally binding?

Yes, the Five Wishes document is legally binding in most states, including the District of Columbia and 42 other states. However, it’s important to check if your state has specific requirements. If you live in a state not listed, the document may still serve as a guide for your wishes, but it may not meet all legal requirements.
How does Five Wishes help my family?

Five Wishes helps your family by providing clear guidance on your preferences. It eliminates the guesswork during difficult times. Your loved ones won’t have to make tough decisions without knowing what you want. This can bring comfort and clarity when they need it most.

5 Wishes Document Example

FIVE

WISH S®

M Y W I S H F O R :

The Person I Want too Make Car1e Decisions for Me When I Can’t

The Kind of Medical Treat2ment I Want or Don’t Want

How Comfortable3 I Want to Be

How I Want People4 to Treat Me

What I Want My Loved5 Ones to Know

print your name

birthdate

Five Wishes

There are many things in life that are out of our hands. This Five Wishes document gives you a way to control somethingg very

important—how you are treated if you get seriously ill. It is ann easy-to- complete form that lets you say exactly what you want. Once it is filled out and properly signed it is valid under the laws off most states.

What Is Five Wishes?

Five Wishes is the first living will that talks about your personal, emotional and spiritual needs as well as your medical wishes. It lets you choose the person you want to make health care decisions for you if you are not able to make them for yourselff. Five Wishes

lets you say exactly how you wish to be

treated if you get seriously ill. It was written with the help of The American Bar

$VVRFLDWLRQ·V&RPPLVVLRQRQ/DZDQG$JLQJ DQGWKHQDWLRQ·VOHDGLQJH[SHUWVLQHQGRIOLIH FDUH,W·VDOVRHDV\WRXVH$OO\RXKDYHWRGRLV check a box, circle a direction, or write a few

sentences.

How Five Wishes Can Help You And Your Family

•

It lets

you talk with your family,

WKH\ZRQ·WKDYHWRPDNHKDUGFKRLFHV

frie

without knowing your wishes.

nds and doctor about how you

wantt

to be treated if you become

• You can know what your mom, dad,

seriou

sly ill.

spouse, or friend wants. You can be

•

Your family membe

rs will not have to

there for them when they need you

t. It protects them

most. You will understand what they

guess what you wan

ously ill, because

really want.

if you become seri

How Five Wishes Began

For 12 years, Jim Towey worked closely with Mother Teresa, and, for one year, he lived in a KRVSLFHVKHUDQLQ:DVKLQJWRQ'&,QVSLUHGE\ WKLVILUVWKDQGH[SHULHQFH0U7RZH\VRXJKWD way for patients and their families to plan ahead and to cope with serious illness. The result is

2Five Wishes and the response to it has been

RYHUZKHOPLQJ,WKDVEHHQIHDWXUHGRQ&11 DQG1%&·V7RGD\6KRZDQGLQWKHSDJHVRI Time and MoneyPDJD]LQHV1HZVSDSHUVKDYH called Five Wishes the first “living will with a heart and soul.” Today, Five Wishes is available in 27 languages.

Who Should Use Five Wishes

Five Wishes is for anyone 18 or older — married, single, parents, adult children, and friends. More than 19 million people of all ages have already used it. Because it

works so well, lawyers, doctors, hospitals and hospices, faith communities, employers, and retiree groups are handing outt this document.

Five Wishes States

If you live in the District of Columbia or one of the 42 states listed below, youu can use )LYH:LVKHVDQGKDYHWKHSHDFHRIPLQGWRNQRZWKDWLWVXEVWDQWLDOO\PHHWV\RXUVWDWH·V requirements under the law:

Alaska

Illinois

Montana

6RXWK&DUROLQD

Arizona

Iowa

1HEUDVND

6RXWK'DNRWD

Arkansas

Kentucky

1HYDGDD

Tennessee

&DOLIRUQLD

/RXLVLDQD

1HZ-HUVH\

Vermont

&RORUDGR

Maine

1HZ0H[LFR

Virginia

&RQQHFWLFXW

Maryland

RUN

Washington

1HZ<

Delaware

Massachusetts

West Virginia

1RUWK&DUROLQD

Florida

Michigan

Wisconsin

1RUWK'DNRWD

Georgia

Minnesota

Oklahoma

Wyoming

Hawaii

Mississippi

Pennsylvania

Idaho

Missouri

Rhode Island

If your state is not one of the 42 states listed here, Five Wishes does not meet the technical UHTXLUHPHQWVLQWKHVWDWXWHVRI\RXUVWDWH6RVRPHGRFWRUVLQ\RXUVWDWHPD\EHUHOXFWDQW to honor Five Wishes. However, many people from states not on this list do complete Five :LVKHVDORQJZLWKWKHLUVWDWH·VOHJDOIRUP7KH\ILQGWKDW)LYH:LVKHVKHOSVWKHPH[SUHVV all that they want and provides a helpful guide to family members, friends, care givers and doctors. Most doctors and health care professionals know they need to listen to your wishes no matter how you express them.

How Do I Change To Five Wishes?

You may already have a living will or a durable power of attorney for health care. If you want to use Five Wishes instead, all you need to do is fill out and sign a new Five Wishes as directed. As soon as you sign it, it takes away any advance directive you had before. To make sure the right form is used, please do the following:

•	D	estroy all copies of your old living will	•	7HOO\RXU+HDOWK&DUH$JHQWIDPLO\
	or durable power of attorney for health			members, and doctor that you have
	care. Or you can write “revoked” in large			filled out a new Five Wishes.
	letters across the copy you have. Tell			Make sure they know about your
	your lawyer if he or she helped prepare			new wishes.
	those old forms for you. AND

WISH 1

The Person I Want To Make Health Care Decisions For Me

When I Can’t Make Them For Myself.

f I am no longer able to make my own health care

• My attending or treating doctor finds I am no

I decisions, this form names the person I choose to

longer able to make health ca

es, AND

re choic

make these choices for me. This person will be my

• Another health care profe

ssional agrees

hat

Health Care Agent (or other term that may be used in

this is true.

MPLE

my state, such as proxy, representative, or surrogate).

If my state has a different

ay of finding that I am not

This person will make my health care choices if both

able to make health c

are choices, then my state’s way

of these things happen:

should be followe

The Person I Choose As My Health Care Agent Is:

First Choice Name

one

Address

City/State/Zip

If this person is not able or willing to make thesee choices for me, OR is divorced or legally separated from me, OR this person has died, then these people aree my next choices:

Second Choice Name

Third Choice Nam

Address

ddress

City/State/Zip

Phone

Picking The R

Your Health Care Agent

ight Person To Be

&KRRVHVRPHRQHZKRNQRZV\RXYHU\ZHOO

DQGIROORZ\RXUZLVKHV<RXU+HDOWK&DUH

can make difficult

Agent should be at least 18 years or older (in

cares about you, and who

ily member may

&RORUDGR\HDUVRUROGHUDQGVKRXOGnot be:

decisions. A spouse or fam

not be the best choice because they are too

•

Your health care provider, including the

YHG6RPHWLPHVWKH\are the

HPRWLRQDOO\LQYRO

owner or operator of a health or residential

EHVWFKRLFH<RX

NQRZEHVW&KRRVHVRPHRQH

or community care facility serving you.

ho is able to stand up for you so that your

wishes are followed. Also, choose someone who

•

An employee or spouse of an employee of

is likely to be nearby so that they can help when

your health care provider.

you need them. Whether you choose a spouse,

SAMIDPLO\PHPEHURUIULHQGDV\RXU+HDOWK&DUH

6HUYLQJDVDQDJHQWRUSUR[\IRURU

Agent, make sure you talk about these wishes

more people unless he or she is your

and be sure that this person agrees to respect

spouse or close relative.

I understand that my Health Care Agent can make health care decisions for me. I want my Agent to be able to do the

following: (Please cross out anything you don’t want your Agent to do that is listed below.)

•	Make choices for me about my medical care		6HH DQGDSSURYHUHOHDVHRIP\PHGLFDOUHFRUGV
	or services, like tests, medicine, or surgery.		and personal files. If I need to sign my name to
	This care or service could be to find out what my		JHWDQ\RIWKHVHILOHVP\+HDOW				$JHQWFDQ
	This care or service could be to find out what my		JHWDQ\RIWKHVHILOHVP\+HDOW			K&DUH	$JHQWFDQ
	health problem is, or how to treat it. It can also		sign it for me.
	include care to keep me alive. If the treatment or	•	Move me to another
	FDUHKDVDOUHDG\VWDUWHGP\+HDOWK&DUHAgent	•	Move me to another		state to get the care I need
	FDUHKDVDOUHDG\VWDUWHGP\+HDOWK&DUHAgent		or to carry out m	y wishes.
	can keep it going or have it stopped.		or to carry out m	y wishes.
	can keep it going or have it stopped.

•Interpret any instructions I have given in

this form or given in other discussions, according

WRP\+HDOWK&DUH$JHQW·VXQGHUVWDQGLQJRIP\ wishes and values.

&RQVHQWWRDGPLVVLRQWRDQDVVLVWHGOLYLQJIDFLOLW\ hospital, hospice, or nursing home for me. My +HDOWK&DUH$JHQWFDQKLUHDQ\NLQGRIKHDOWK care worker I may need to help me or take care of me. My Agent may also fire a health care worker, if needed.

•Make the decision to request, take away or not

JLYHPHGLFDOWUHDWPHQWVLQFOXGLQJDUWLILFLDOO\ provided food and water, andd any other treatments to keepp me alive.

•Authorize or refuse to authorize any medication or procedure needed to help with pain.

•Take any legal action needed to carry out my wishes.

•Donate useable organs or tissues of mine as allowed by law.

• Apply for Medicare, Medicaid, or other programs RULQVXUDQFHEHQHILWVIRUPH0\+HDOWK&DUH Agent can see my personal files, like bank records, to find out what is needed to fill out these forms.

/LVWHGEHORZDUHDQ\FKDQJHVDGGLWLRQVRU OLPLWDWLRQVRQP\+HDOWK&DUH$JHQW·VSRZHUV

______________________________________________________________________________

If I Change My Mind About Having A Health Care Agent, I Will

•	Destroy all copies of this part of the	• Write the word “Revoked” in large
	Five Wishes form. OR	letters across the name of each agent
• Tell someone, such as my doctor or		whose authority I want to cancel.
• Tell someone, such as my doctor or		6LJQP\QDPHRQWKDWSDJH
	family, that I want to cancel or change	6LJQP\QDPHRQWKDWSDJH
	family, that I want to cancel or change
	P\+HDOWK&DUH$JHQWOR

WISH 2

My Wish For The Kind Of Medical Treatment

I Want Or Don’t Want.

I b elieve that my life is precious and I deserve to be treated with dignity. When the timee comes that

I am very sick and am not able to speak for myself, I want the following wishes, and any other directions I have given to my Health Care Agent, to be respected and followed.

What You Should Keep In Mind As My Caregiver

•I do not want to be in pain. I want my doctor to give me enough medicine to relieve my pain, even if that means that I will be drowsy or sleep more than I would otherwise.

•I do nott want anything done or omitted by my doctors or nurses with the intention of taking my life.

•I want to be offered food and fluids by mouth, and kept clean and warm.

What “Life-Support Treatment” Means To Me

/LIHVXSSRUWWUHDWPHQWPHDQVDQ\PHGLFDOSURFH dure, device or medication to keep me alive.

/LIHVXSSRUWWUHDWPHQWLQFOXGHVPHGLFDO devices put in me to help me breathe; food and ZDWHUVXSSOLHGE\PHGLFDOGHYLFHWXEHIHHGLQJ FDUGLRSXOPRQDU\UHVXVFLWDWLRQ&35PDMRU surgery; blood transfusions; dialysis; antibiotics;

and anything else meant to keep me alive.

,I,ZLVKWROLPLWWKHPHDQLQJRIOLIHVXSSRUW treatment because of my religious or personal beliefs, I write this limitation in the space below. I do this to make very clear what I want and under what conditions.

_________________________________________________________________________________________

In Case Of An Emergency

Iff you have a medical emergency and ambulance personnel arrive, they may look to see if you have a Do Not Resuscitate form or bracelet. Many states require a person to have a Do Not Resuscitate form filled out and

signed by a doctor. This form lets ambulance SHUVRQQHONQRZWKDW\RXGRQ·WZDQWWKHPWRXVH OLIHVXSSRUWWUHDWPHQWZKHQ\RXDUHG\LQJ3OHDVH check with your doctor to see if you need to have a Do Not Resuscitate form filled out.

Here is the kind of medical treatment that I want or don’t want in the four situations listed below. I want my Health Care Agent, my family, my doctors and other health care providers, my friends and all others to know these directions.

Close to death:

If my doctor and another health care professional both decide that I am likely to die within a short period of WLPHDQGOLIHVXSSRUWWUHDWPHQWZRXOGRQO\GHOD\WKH PRPHQWRIP\GHDWK&KRRVHoneRIWKHIROORZLQJ

❏ ,ZDQWWRKDYHOLIHVXSSRUWWUHDWPHQW

❏ , GRQRWZDQWOLIHVXSSRUWWUHDWPHQW,ILWKDV been started, I want it stopped.

❏,ZDQWWRKDYHOLIHVXSSRUWWUHDWPHQWLIP\GRFWRU believes it could help. But I want my doctor to

VWRSJLYLQJPHOLIHVXSSRUWWUHDWPHQWLILWLVQRW helping my health condition or symptoms.

In A Coma And Not Expected Too Wake Up Or Recover:

If my doctor and another health care professional both decide that I am in a coma from which I am not expected WRZDNHXSRUUHFRYHUDQG,KDYHEUDLQGDPDJHDQGOLIH support treatment would only delay the moment of my GHDWK&KRRVHoneRIWKHIROORZLQJ

❏ ,ZDQWWRKDYHOLIHVXSSRUWWUHDWPHQW

❏ , GRQRWZDQWOLIHVXSSRUWWUHDWPHQW,ILWKDV been started, I want it stopped.

❏,ZDQWWRKDYHOLIHVXSSRUWWUHDWPHQWLIP\GRFWRU believes it could help. But I want my doctor to

VWRSJLYLQJPHOLIHVXSSRUWWUHDWPHQWLILWLVQRW helping my health condition or symptoms.

Permanent And Severe Brain Damage And Not Expected To Recover:

If my doctor and another health care professional both decide that I have permanentt and severe brain damage,

(for example, I can open myy eyes, but I can not speak RUXQGHUVWDQGDQG,DPQRWH[SHFWHGWRJHWEHWWHUDQG OLIHVXSSRUWWUHDWPHQWZRXOGRQO\GHOD\WKHPRPHQWRI P\GHDWK&KRRVHoneRIWKHIROORZLQJ

❏ ,ZDQWWRKDYHOLIHVXSSRUWWUHDWPHQW

❏ ,GRQRWZDQWOLIHVXSSRUWWUHDWPHQW,ILWKDV been started, I want it stopped.

❏,ZDQWWRKDYHOLIHVXSSRUWWUHDWPHQWLIP\GRFWRU believes it could help. But I want my doctor to

VWRSJLYLQJPHOLIHVXSSRUWWUHDWPHQWLILWLVQRW helping my health condition or symptoms.

In Another Condition Under Which I Do Not Wish To Be Kept Alive:

If there is another condition under which I do not wish WRKDYHOLIHVXSSRUWWUHDWPHQW,GHVFULEHLWEHORZ,Q this condition, I believe that the costs and burdens of

OLIHVXSSRUWWUHDWPHQWDUHWRRPXFKDQGQRWZRUWKWKH benefits to me. Therefore, in this condition, I do not want OLIHVXSSRUWWUHDWPHQW)RUH[DPSOH\RXPD\ZULWH ´HQGVWDJHFRQGLWLRQµ7KDWPHDQVWKDW\RXUKHDOWKKDV gotten worse. You are not able to take care of yourself in DQ\ZD\PHQWDOO\RUSK\VLFDOO\/LIHVXSSRUWWUHDWPHQW will not help you recover. Please leave the space blank if \RXKDYHQRRWKHUFRQGLWLRQWRGHVFULEH

________________________________________________________________________________________

Th e next three wishes deal with my personal, spiritual and emotional wishes. They are important to me. I want to be treated with dignity near the end of my life, so I would like people to do the things

written in Wishes 3, 4, and 5 when they can be done. I understand that my family, my doctors and other health care providers, my friends, and others may not be able to do these things or are not required by law to do these things. I do not expect the following wishes to place new or added legal duties on my doctors or other health care providers. I also do not expect these wishes to excuse my doctor or other health care providers from giving mee the proper care asked for by law.

WISH 3

My Wish For How Comfortable I Want To Bee.

(Please cross out anything that you don’t agree with.)

•I do not want to be in pain. I want my doctor to give me enough medicine to relieve my pain, even if that means I will be drowsy or sleep more than I would otherwise.

•If I show signs of depression, nausea, shortness of breath, or hallucinations, I want my care givers to do whatever they can to help me.

•I wish to have a cool moist cloth put onn my head if I have a fever.

•I want my lips and mouth kept moist to stop dryness.

•I wish to have warm baths often. I wish to be kept fresh and clean at all times.

•I wishh to be massaged with warm oils as often as I can be.

•I wish to have my favorite music played when possible until my time of death.

•I wish to have personal care like shaving, nail clipping, hair brushing, and teeth brushing, as long as they do not cause me pain or discomfort.

,ZLVKWRKDYHUHOLJLRXVUHDGLQJVDQGZHOO loved poems read aloud when I am near death.

•I wish to know about options for hospice care to provide medical, emotional and spiritual care for me and my loved ones.

WISH 4

My Wish For How I Want People To Treat Me.

(Please cross out anything that you don’t agree with.)

•I wish to have people with me when possible. I want someone to be with me when it seems that death may come at any time.

•I wish to have my hand held and to be talked

WRZKHQSRVVLEOHHYHQLI,GRQ·WVHHPWR respond to the voice or touch of others.

•I wish to have others by my side praying for me when possible.

•I wish to have the members of my faith community told that I am sick and asked to pray for me and visit me.

•I wish to be cared for with kindness and cheerfulness, and not sadness.

•I wish to have pictures of my loved ones in my room, near my bed.

•If I am not able to control my bowel or bladder functions, I wish for my clothes and bed linens to be kept clean, and for them to be changed as soon as they can be if they have been soiled.

•I want to die in my home, if that can be done.

WISH 5

My Wish For What I Want My Loved Ones To Know.

(Please cross out anything that you don’t agree with.)

•I wish to have my family and friends know that I love them.

•I wish to be forgiven for the times I have hurt my family, friends, and others.

•I wish to have my family, friends and others know that I forgive them for when they may have hurt me in my life.

•I wish for my family and friends to know that I do not fear death itself. I think it is not the end, but a new beginning for me.

•I wish for all of my family members to make peace with each other before my death, if they can.

•I wish for my family and friends to think about what I was like before I became seriously ill. I want them too remember me in this way after my death.

•I wish for my family and friends and caregivers to respect my wishes even if

WKH\GRQ·WDJUHHZLWKWKHP

•I wish for my family and friends to look at my dying as a time of personal growth for everyone, including me. This will help me livee a meaningful life in my final days.

•I wish for my family and friends to get counseling if they have trouble with my death. I want memories of my life to give

WKHPMR\DQGQRWVRUURZ

•After my death, I would like my body to

EHFLUFOHRQHEXULHGRUFUHPDWHG

•My body or remains should be put in the

following

location

•The following person knows my funeral

wishes:.

If anyone asks how I want to be remembered, please say the following about me:

_________________________________________________________________________________

If there is to bee a memorial service for me, I wish for this service to include the following

OLVWPXVLFVRQJVUHDGLQJVRURWKHUVSHFLILFUHTXHVWVWKDW\RXKDYH

_________________________________________________________________________________

(Please use the space below for any other wishes. For example, you may want to donate any or all parts of your body when you die. You may also wish to designate a charity to receive memorial contributions. Please attach a VH DUDWHVKHHWRI D HULI\RXQHHGPRUHVSDFH

______________________________________________________________________________________

Signing The Five Wishes Form

Please make sure you sign your Five Wishes form in the presence of the two witnesses.

I, _________________________________, ask that my family, my doctors, and other health care providers,

P\IULHQGVDQGDOORWKHUVIROORZP\ZLVKHVDVFRPPXQLFDWHGE\P\+HDOWK&DUH$JHQWLI,KDYHRQHDQGKH RUVKHLVDYDLODEOHRUDVRWKHUZLVHH[SUHVVHGLQWKLVIRUP7KLVIRUPEHFRPHVYDOLGZKHQ,DPXQDEOHWRPDNH decisions or speak for myself. If any part of this form cannot be legally followed, I ask that all other parts of this form be followed. I also revoke any health care advance directives I have made before.

Signature:		___
Address:
Phone:	Date:		__

Witness Statement • (2 witnesses needed):

,WKHZLWQHVVGHFODUHWKDWWKHSHUVRQZKRVLJQHGRUDFNQRZOHGJHGWKLVIRUPKHUHDIWHU´SHUVRQµLVSHUVRQDOO\NQRZQWR PHWKDWKHVKHVLJQHGRUDFNQRZOHGJHGWKLV>+HDOWK&DUH$JHQWDQGRU/LYLQJ:LOOIRUPV@LQP\SUHVHQFHDQGWKDWKHVKH appears to be of sound mind and under no duress, fraud, or undue influence.

,DOVRGHFODUHWKDW,DPRYHU\HDUVRIDJHDQGDP127

•The individual appointed as (agent/proxy/

VXUURJDWHSDWLHQWDGYRFDWHUHSUHVHQWDWLYHE\ this document or his/her successor,

•7KHSHUVRQ·VKHDOWKFDUHSURYLGHULQFOXGLQJ RZQHURURSHUDWRURIDKHDOWKORQJWHUPFDUH or other residential or community care facility serving the person,

•$QHPSOR\HHRIWKHSHUVRQ·VKHDOWKFDUH provider,

•)LQDQFLDOO\UHVSRQVLEOHIRUWKHSHUVRQ·V 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.

(Some states may have fewer rules about who may be a witness. Unless you know your state’s rules, please follow the above.)


Signature of Witness				Signature of Witness #2
Signature of Witness			#1	Signature of Witness #2

Printed Name of Witn				Printed Name of Witness
Printed Name of Witn		ess		Printed Name of Witness

Address				Address

				Phone
	Phone
	Phone

Notarization • Only required for residents of Missouri, North Carolina, South Carolina and West Virginia

•If you live in Missouri, only your signature should be notarized.

•,I\RXOLYHLQ1RUWK&DUROLQD6RXWK&DUROLQDRU:HVW9LUJLQLD you should have your signature, and the signatures of your witnesses, notarized.

67$7(2)BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB&2817<2)BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB

2QWKLVBBBBBGD\RIBBBBBBBBBBBBBBBBBBBBBBBWKHVDLGBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBDQGBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBNQRZQWRPHRUVDWLVIDFWRULO\SURYHQWREHWKHSHUVRQQDPHGLQWKH IRUHJRLQJLQVWUXPHQWDQGZLWQHVVHVUHVSHFWLYHO\SHUVRQDOO\DSSHDUHGEHIRUHPHD1RWDU\3XEOLFZLWKLQDQGIRUWKH6WDWHDQG&RXQW\DIRUHVDLGDQG acknowledged that they freely and voluntarily executed the same for the purposes stated therein.

0\&RPPLVVLRQ([SLUHV						BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
10						1RWDU\3XEOLF

Consider More Forms

Passport Paperwork - The DS-11 form must be submitted in person at an authorized acceptance facility.

When starting a new business in New York, it's crucial to complete the necessary paperwork, and the Articles of Incorporation is one of the most significant aspects of this process. This document not only details the corporation's name and purpose but also includes essential information about its office address and incorporators. For those looking to simplify this process, a great resource is available at All New York Forms, which offers a free template to help ensure all details are accurately captured.

Restraining Order Template - Diligence in following legal protocols is required to ensure the effectiveness of the order.