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Fill Out Your 5 Wishes Document Template

The Five Wishes Document is a unique form that allows individuals to express their personal, emotional, and spiritual needs regarding medical treatment and care. This document empowers you to designate a trusted person to make health care decisions on your behalf when you are unable to do so. By clearly outlining your preferences, the Five Wishes Document ensures that your wishes are respected, providing peace of mind for both you and your loved ones.

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Fill Out Your 5 Wishes Document Template

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The Five Wishes document serves as a comprehensive tool for individuals seeking to communicate their healthcare preferences in the event of a serious illness. It encompasses five key areas: the selection of a trusted person to make healthcare decisions on one’s behalf, the specific medical treatments one desires or wishes to avoid, the level of comfort desired during treatment, the manner in which one wants to be treated by caregivers and loved ones, and important messages for family and friends. This document is designed to facilitate open discussions among family members, ensuring that they are aware of each other’s wishes and can act accordingly during challenging times. Created to address not only medical needs but also emotional and spiritual considerations, Five Wishes is recognized as the first living will of its kind. It is straightforward to complete, requiring individuals to check boxes, circle options, or write brief notes, making it accessible for a broad audience. Once signed, it holds legal validity in most states, allowing individuals to retain a degree of control over their healthcare decisions even when they are unable to voice them. With over 19 million users, Five Wishes has gained traction among various groups, including healthcare professionals, legal advisors, and community organizations, highlighting its importance in end-of-life planning.

Similar forms

The Five Wishes document is similar to a living will, which is a legal document that outlines an individual's preferences for medical treatment in situations where they are unable to communicate their wishes. Like Five Wishes, a living will allows individuals to specify the types of medical interventions they would or would not want. Both documents serve to guide healthcare providers and loved ones in making decisions that align with the individual’s values and desires during critical health situations.

Another document akin to Five Wishes is a durable power of attorney for healthcare. This legal instrument designates a specific person to make healthcare decisions on behalf of an individual if they become incapacitated. Similar to Five Wishes, it empowers a chosen representative to act in the best interests of the individual, ensuring that their healthcare preferences are honored. However, while a durable power of attorney focuses primarily on decision-making authority, Five Wishes encompasses emotional and spiritual considerations as well.

The advance directive is also comparable to the Five Wishes document. An advance directive is a broader term that includes any legal document that specifies an individual’s healthcare preferences. It can include both living wills and durable powers of attorney. Five Wishes fits within this category by providing a comprehensive approach that covers not only medical treatments but also personal comfort and emotional support, making it a more holistic option for individuals planning for future healthcare needs.

Health care proxies are another document that shares similarities with Five Wishes. A health care proxy is a person designated to make medical decisions on behalf of another individual. Like Five Wishes, it allows individuals to select someone they trust to advocate for their healthcare choices. However, Five Wishes goes further by enabling individuals to articulate their specific preferences and values, providing a clearer framework for their proxy to follow.

The Physician Orders for Life-Sustaining Treatment (POLST) form is also related to Five Wishes. POLST is a medical order that specifies the types of medical interventions a patient wishes to receive during a medical emergency. While POLST is typically used in conjunction with a living will or advance directive, it is more focused on immediate medical care decisions. In contrast, Five Wishes includes a broader range of personal and emotional preferences, allowing for a more comprehensive expression of an individual’s desires regarding end-of-life care.

For those looking to establish clear guidelines within their organization, a crucial resource is the comprehensive Employee Handbook template available online. This document provides an essential framework for defining company policies and expectations while ensuring employees understand their rights and responsibilities. To explore more about this invaluable tool, visit the key Employee Handbook resource.

Lastly, the Do Not Resuscitate (DNR) order is another document that bears resemblance to Five Wishes. A DNR order specifically instructs healthcare providers not to perform CPR if a patient stops breathing or their heart stops beating. While this document addresses a specific medical scenario, Five Wishes encompasses a wider array of wishes and preferences, offering individuals a more detailed opportunity to communicate their values and desires regarding their overall care.

Form Specifications

Fact Name	Fact Description
Purpose	The Five Wishes document allows individuals to express their medical, emotional, and spiritual preferences for healthcare when they cannot speak for themselves.
Validity	Once completed and signed, the Five Wishes document is valid in most states across the U.S.
Age Requirement	Anyone aged 18 or older can complete the Five Wishes document, regardless of marital status.
Healthcare Agent	Five Wishes allows you to designate a healthcare agent to make decisions on your behalf if you are unable to do so.
State-Specific Laws	In states like California, Five Wishes complies with the California Health Care Decisions Law.
Ease of Use	The form is designed to be straightforward, requiring simple actions like checking boxes or writing brief responses.
Language Availability	Five Wishes is available in 27 languages, making it accessible to a diverse population.

Free 5 Wishes Document

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Sample - 5 Wishes Document Form

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

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Arizona

Iowa

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6RXWK'DNRWD

Arkansas

Kentucky

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Tennessee

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/RXLVLDQD

1HZ-HUVH\

Vermont

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Maine

1HZ0H[LFR

Virginia

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Maryland

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Washington

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Delaware

Massachusetts

West Virginia

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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

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owner or operator of a health or residential

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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,

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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.

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______________________________________________________________________________

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

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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

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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

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•After my death, I would like my body to

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•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.

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