|
||||||||||||||||||||||||||||||||||||||||||||
|
||||||||||||||||||||||||||||||||||||||||||||
| ||||||||||||||||||||||||||||||||||||||||||||
| ||||||||||||||||||||||||||||||||||||||||||||
| ||||||||||||||||||||||||||||||||||||||||||||
1 | AN ACT concerning civil law.
| |||||||||||||||||||||||||||||||||||||||||||
2 | Be it enacted by the People of the State of Illinois,
| |||||||||||||||||||||||||||||||||||||||||||
3 | represented in the General Assembly:
| |||||||||||||||||||||||||||||||||||||||||||
4 | Section 5. The Illinois Power of Attorney Act is amended by | |||||||||||||||||||||||||||||||||||||||||||
5 | changing Sections 2-1, 2-5, 2-8, 2-10, 2-11, 3-3, 4-10, and | |||||||||||||||||||||||||||||||||||||||||||
6 | 4-12 and by adding Sections 2-10.5, 2-10.6, 3-3.5, 3-3.6, and | |||||||||||||||||||||||||||||||||||||||||||
7 | 4-5.1, as follows:
| |||||||||||||||||||||||||||||||||||||||||||
8 | (755 ILCS 45/2-1) (from Ch. 110 1/2, par. 802-1)
| |||||||||||||||||||||||||||||||||||||||||||
9 | Sec. 2-1. Purpose. The General Assembly recognizes that | |||||||||||||||||||||||||||||||||||||||||||
10 | each
individual has the right to appoint an agent to make deal | |||||||||||||||||||||||||||||||||||||||||||
11 | with property , financial, or make
personal , and health care | |||||||||||||||||||||||||||||||||||||||||||
12 | decisions for the individual but that this right
cannot be | |||||||||||||||||||||||||||||||||||||||||||
13 | fully effective unless the principal may empower the agent to | |||||||||||||||||||||||||||||||||||||||||||
14 | act
throughout the principal's lifetime, including during | |||||||||||||||||||||||||||||||||||||||||||
15 | periods of
disability, and have confidence be sure that third | |||||||||||||||||||||||||||||||||||||||||||
16 | parties will honor the agent's authority
at all times.
| |||||||||||||||||||||||||||||||||||||||||||
17 | The General Assembly finds that in the light of modern | |||||||||||||||||||||||||||||||||||||||||||
18 | financial needs
and advances in medical science, the statutory | |||||||||||||||||||||||||||||||||||||||||||
19 | recognition of this right of
delegation in Illinois needs to be | |||||||||||||||||||||||||||||||||||||||||||
20 | restated which will to , among other things, expand the
its | |||||||||||||||||||||||||||||||||||||||||||
21 | application and the permissible scope of the agent's authority, | |||||||||||||||||||||||||||||||||||||||||||
22 | clarify
the power of the individual to authorize an agent to | |||||||||||||||||||||||||||||||||||||||||||
23 | make financial and
care decisions for the individual and better |
| |||||||
| |||||||
1 | protect health care personnel
and other third parties who rely | ||||||
2 | in good faith on the agent so that
reliance will be assured. | ||||||
3 | Nothing in this Act shall be deemed to
authorize or encourage | ||||||
4 | euthanasia, suicide or any action or course of
action that | ||||||
5 | violates the criminal law of this State or the United States.
| ||||||
6 | Similarly, nothing in this Act shall be deemed to authorize or | ||||||
7 | encourage
any violation of a civil right expressed in the | ||||||
8 | Constitution, statutes,
case law and administrative rulings of | ||||||
9 | this State (including, without
limitation, the right of | ||||||
10 | conscience respected and protected by the Health
Care Right of | ||||||
11 | Conscience Act, as now or hereafter amended) or the
United | ||||||
12 | States or any action or course of action that violates the | ||||||
13 | public policy
expressed in the Constitution, statutes, case law | ||||||
14 | and administrative rulings of
this State or the United States.
| ||||||
15 | (Source: P.A. 90-655, eff. 7-30-98.)
| ||||||
16 | (755 ILCS 45/2-5) (from Ch. 110 1/2, par. 802-5)
| ||||||
17 | Sec. 2-5. Duration of agency - amendment and revocation. | ||||||
18 | Unless the
agency states an earlier termination date, the | ||||||
19 | agency continues until the
death of the principal, | ||||||
20 | notwithstanding any lapse of time, the principal's
disability | ||||||
21 | or incapacity or appointment of a guardian for the principal
| ||||||
22 | after the agency is signed. Every agency may be amended or | ||||||
23 | revoked by the
principal , if the principal has the capacity to | ||||||
24 | do so, at any time and in any manner communicated to the agent | ||||||
25 | or to any
other person related to the subject matter of the |
| |||||||
| |||||||
1 | agency, except that
revocation and amendment of health care | ||||||
2 | agencies are governed by Section 4-6
of this Act except to the | ||||||
3 | extent the terms of the agencies are inconsistent
with that | ||||||
4 | Section.
| ||||||
5 | (Source: P.A. 86-736.)
| ||||||
6 | (755 ILCS 45/2-8) (from Ch. 110 1/2, par. 802-8)
| ||||||
7 | Sec. 2-8.
Reliance on
document purporting to establish an
| ||||||
8 | agency. Any person who acts in good faith
reliance on a copy of
| ||||||
9 | a document purporting to establish an agency will be fully | ||||||
10 | protected and
released to
the same extent as though the reliant | ||||||
11 | had dealt directly with the
named
principal
as a | ||||||
12 | fully-competent person. The
named
agent shall furnish an | ||||||
13 | affidavit to the
reliant on demand stating that the instrument | ||||||
14 | relied on is a true copy of
the agency and that, to the best of | ||||||
15 | the
named
agent's knowledge, the named principal is
alive and | ||||||
16 | the relevant powers of the
named
agent have not been altered or
| ||||||
17 | terminated; but good faith reliance on
a document purporting to | ||||||
18 | establish an agency will protect the reliant
without the | ||||||
19 | affidavit. | ||||||
20 | (a) Upon request, the named agent in a power of attorney | ||||||
21 | shall furnish a Certification and Acceptance of Authority to | ||||||
22 | the reliant in substantially the following form: | ||||||
23 | AGENT'S CERTIFICATION AND ACCEPTANCE |
| |||||||
| |||||||
1 | I, (Name of Agent), certify that the attached is a true | ||||||
2 | copy of a Power of Attorney naming the undersigned as agent or | ||||||
3 | successor agent for (Name of Principal); and | ||||||
4 | I certify that to the best of my knowledge the Principal is | ||||||
5 | alive and has not revoked the Power of Attorney and that my | ||||||
6 | powers as agent have not been altered or terminated and that | ||||||
7 | the Power of Attorney remains in full force and effect. | ||||||
8 | I accept appointment as agent under this Power of Attorney. | ||||||
9 | Dated:............ | ||||||
10 | ....................... | ||||||
11 | (Agent's Signature) | ||||||
12 | ....................... | ||||||
13 | (Print Agent's Name) | ||||||
14 | ....................... | ||||||
15 | (Agent's Address) | ||||||
16 | This document was acknowledged, signed and sworn to before | ||||||
17 | me on (date) by (Name of Agent). | ||||||
18 | [SEAL] | ||||||
19 | My commission expires............. ..................... | ||||||
20 | (Signature of Notary) | ||||||
21 | (b) Any person dealing with an agent
named in a copy of a | ||||||
22 | document purporting to establish an agency
may presume, in
the | ||||||
23 | absence of actual knowledge to the contrary, that the
document |
| |||||||
| |||||||
1 | purporting to establish the
agency was
validly executed,
that | ||||||
2 | the agency was validly established,
that the named principal | ||||||
3 | was competent at the time
of execution, and that, at the time | ||||||
4 | of reliance, the
named
principal is alive,
the agency
was | ||||||
5 | validly established
and has not terminated or been amended, the | ||||||
6 | relevant powers of the
named
agent were properly and validly | ||||||
7 | granted and have not terminated or
been amended, and the acts | ||||||
8 | of the
named
agent conform to the standards of this Act.
No | ||||||
9 | person relying on
a copy of a document purporting to establish | ||||||
10 | an agency shall be required to see to the application
of any | ||||||
11 | property delivered to or controlled by the
named
agent or to | ||||||
12 | question the
authority of the
named
agent. | ||||||
13 | (c) Each person to whom a direction by the named agent in
| ||||||
14 | accordance with the terms of the
copy of the document | ||||||
15 | purporting to establish an
agency is communicated shall comply | ||||||
16 | with
that direction, and any person who fails to comply | ||||||
17 | arbitrarily or without
reasonable cause shall be subject to | ||||||
18 | civil liability for any damages
resulting from noncompliance.
A | ||||||
19 | health care provider who complies with Section 4-7 shall not be
| ||||||
20 | deemed to have acted arbitrarily or without reasonable cause.
| ||||||
21 | (Source: P.A. 90-21, eff. 6-20-97.)
| ||||||
22 | (755 ILCS 45/2-10) (from Ch. 110 1/2, par. 802-10)
| ||||||
23 | Sec. 2-10. Agency-court relationship. | ||||||
24 | (a) Upon petition by any interested
person (including the | ||||||
25 | agent), with such notice to interested persons as the
court |
| |||||||
| |||||||
1 | directs and a finding by the court that the principal
lacks | ||||||
2 | either the capacity to control or the capacity to revoke the | ||||||
3 | agency , the court may construe a power of attorney, review the | ||||||
4 | agent's conduct, and grant appropriate relief including | ||||||
5 | compensatory damages. : (a) if | ||||||
6 | (b) If the court finds
that the agent is not acting for the | ||||||
7 | benefit of the principal in accordance
with the terms of the | ||||||
8 | agency or that the agent's action or inaction has
caused or | ||||||
9 | threatens substantial harm to the principal's person or | ||||||
10 | property
in a manner not authorized or intended by the | ||||||
11 | principal, the court may
order a guardian of the principal's | ||||||
12 | person or estate to exercise any powers
of the principal under | ||||||
13 | the agency, including the power to revoke the
agency, or may | ||||||
14 | enter such other orders without appointment of a guardian as
| ||||||
15 | the court deems necessary to provide for the best interests of | ||||||
16 | the
principal . | ||||||
17 | (c) If ; or (b) if the court finds that the agency requires
| ||||||
18 | interpretation, the court may construe the agency and instruct | ||||||
19 | the agent,
but the court may not amend the agency. | ||||||
20 | (d) If the court finds that the agent has not acted for the | ||||||
21 | benefit of the principal in accordance with the terms of the | ||||||
22 | agency and the Illinois Power of Attorney Act, or that the | ||||||
23 | agent's action or inaction caused or threatened substantial | ||||||
24 | harm to the principal's person or property in a manner not | ||||||
25 | authorized or intended by the principal, then the agent shall | ||||||
26 | not be authorized to pay or be reimbursed from the estate of |
| |||||||
| |||||||
1 | the principal the attorneys' fees and costs of the agent in | ||||||
2 | defending a proceeding brought pursuant to this Section. | ||||||
3 | (e) Upon a finding that the agent's action has caused | ||||||
4 | substantial harm to the principal's person or property, the | ||||||
5 | Court may assess against the agent reasonable costs and | ||||||
6 | attorney's fees to a prevailing party who is a provider agency | ||||||
7 | as defined in Section 2 of the Elder Abuse and Neglect Act, a | ||||||
8 | representative of the Office of the State Long Term Care | ||||||
9 | Ombudsman, or a governmental agency having regulatory | ||||||
10 | authority to protect the welfare of the principal. | ||||||
11 | (f) An interested person under this Section includes (1) | ||||||
12 | the principal or the agent; (2) a guardian of the person, | ||||||
13 | guardian of the estate, or other fiduciary charged with | ||||||
14 | management of the principal's property; (3) the principal's | ||||||
15 | spouse, parent, or descendant; (4) a person who would be a | ||||||
16 | presumptive heir-at-law of the principal: (5) a person named as | ||||||
17 | a beneficiary to receive any property, benefit, or contractual | ||||||
18 | right on the principal's death, or as a beneficiary of a trust | ||||||
19 | created by or for the principal; (6) a provider agency as | ||||||
20 | defined in Section 2 of the Elder Abuse and Neglect Act, a | ||||||
21 | representative of the Office of the State Long Term Care | ||||||
22 | Ombudsman, or a governmental agency having regulatory | ||||||
23 | authority to protect the welfare of the principal; and (7) the | ||||||
24 | principal's caregiver or another person who demonstrates | ||||||
25 | sufficient interest in the principal's welfare. | ||||||
26 | (g) Absent court order directing a
guardian to exercise |
| |||||||
| |||||||
1 | powers of the principal under the agency, a guardian
will have | ||||||
2 | no power, duty or liability with respect to any property | ||||||
3 | subject
to the agency or any personal or health care matters | ||||||
4 | covered by the agency. | ||||||
5 | (h)
Proceedings under this Section shall be commenced in | ||||||
6 | the county where the
guardian was appointed or, if no Illinois | ||||||
7 | guardian is acting, then in the
county where the agent or | ||||||
8 | principal resides or owns real property , if the agent does not | ||||||
9 | reside in
Illinois, then in any county .
| ||||||
10 | (i) This Section shall not be construed to limit any other | ||||||
11 | remedies available. | ||||||
12 | (Source: P.A. 85-701.)
| ||||||
13 | (755 ILCS 45/2-10.5 new)
| ||||||
14 | Sec. 2-10.5. Co-agents and successor agents. | ||||||
15 | (a) Unless the power of attorney or this Section otherwise | ||||||
16 | provides, authority granted to 2 or more co-agents is | ||||||
17 | exercisable only by their majority consent. However, if prompt | ||||||
18 | action is required to accomplish the purposes of the power of | ||||||
19 | attorney or to avoid irreparable injury to the principal's | ||||||
20 | interests and an agent is unavailable because of absence, | ||||||
21 | illness, or other temporary incapacity, the other agent or | ||||||
22 | agents may act for the principal. If a vacancy occurs in one or | ||||||
23 | more of the designations of agent under a power of attorney, | ||||||
24 | the remaining agent or agents may act for the principal. | ||||||
25 | (b) A principal may designate one or more successor agents |
| |||||||
| |||||||
1 | to act if an initial or predecessor agent resigns, dies, | ||||||
2 | becomes incapacitated, is not qualified to serve, or declines | ||||||
3 | to serve. A principal may grant authority to another person, | ||||||
4 | designated by name, by office, or by function, including an | ||||||
5 | initial or successor agent, to designate one or more successor | ||||||
6 | agents. Unless a power of attorney otherwise provides, a | ||||||
7 | successor agent has the same authority as that granted to an | ||||||
8 | initial agent. | ||||||
9 | (c) An agent is not liable for the actions of another | ||||||
10 | agent, including a predecessor agent, unless the agent | ||||||
11 | participates in or conceals a breach of fiduciary duty | ||||||
12 | committed by the other agent. An agent who has knowledge of a | ||||||
13 | breach or imminent breach of fiduciary duty by another agent | ||||||
14 | must notify the principal and, if the principal is | ||||||
15 | incapacitated, take whatever actions may be reasonably | ||||||
16 | appropriate in the circumstances to safeguard the principal's | ||||||
17 | best interest. | ||||||
18 | (d) Any person who acts in good faith reliance on the | ||||||
19 | representation of a co-agent or successor agent regarding the | ||||||
20 | unavailability of the primary agent or one or more co-agents, | ||||||
21 | or the need for prompt action to accomplish the purposes of the | ||||||
22 | power of attorney or to avoid irreparable injury to the | ||||||
23 | principal's interests, will be fully protected and released to | ||||||
24 | the same extent as though the reliant had dealt directly with | ||||||
25 | all named agents. Upon request, the named agent in a Power of | ||||||
26 | Attorney for Property shall furnish a Certification and |
| |||||||
| |||||||
1 | Acceptance of Authority to the reliant in substantially the | ||||||
2 | following form:
| ||||||
3 | AGENT'S CERTIFICATION AND ACCEPTANCE | ||||||
4 | I certify that to the best of my knowledge that the | ||||||
5 | following named agent is unavailable due to (death, | ||||||
6 | resignation, absence, illness, or other temporary incapacity) | ||||||
7 | (circle reason). | ||||||
8 | I certify that prompt action is required to accomplish the | ||||||
9 | purposes of the power of attorney or to avoid irreparable | ||||||
10 | injury to the principal's interests. | ||||||
11 | I accept appointment as agent under this Power of Attorney. | ||||||
12 | Dated:............ | ||||||
13 | ....................... | ||||||
14 | (Agent's Signature) | ||||||
15 | ....................... | ||||||
16 | (Print Agent's Name) | ||||||
17 | ....................... | ||||||
18 | (Agent's Address) | ||||||
19 | This document was acknowledged, signed and sworn to before | ||||||
20 | me on (date) by (Name of Agent). | ||||||
21 | [SEAL] | ||||||
22 | My commission expires.......... | ||||||
23 | ...................... | ||||||
24 | (Signature of Notary) |
| |||||||
| |||||||
1 | (755 ILCS 45/2-10.6 new)
| ||||||
2 | Sec. 2-10.6. Power of attorney executed in another state or | ||||||
3 | country; pre-existing powers of attorney. | ||||||
4 | (a) A power of attorney executed in another state or | ||||||
5 | country is valid and enforceable in this State if its creation | ||||||
6 | complied when executed with: | ||||||
7 | (1) the law of the state or country in which the power | ||||||
8 | of attorney was executed; | ||||||
9 | (2) the law of this State; | ||||||
10 | (3) the law of the state or country where the principal | ||||||
11 | is domiciled, has a place of abode or business, or is a | ||||||
12 | national; or | ||||||
13 | (4) the law of the state or country where the agent is | ||||||
14 | domiciled or has a place of business. | ||||||
15 | (b) A power of attorney executed in this State before the | ||||||
16 | effective date of this amendatory Act of the 96th General | ||||||
17 | Assembly is valid and enforceable in this State if its creation | ||||||
18 | complied with the law of this State as it existed at the time | ||||||
19 | of execution.
| ||||||
20 | (755 ILCS 45/2-11) (from Ch. 110 1/2, par. 802-11)
| ||||||
21 | Sec. 2-11. Saving clause. This Act does not in any way
| ||||||
22 | invalidate any agency executed or any act of any agent done, or
| ||||||
23 | affect any claim, right or remedy that accrued, prior to
| ||||||
24 | September 22, 1987.
| ||||||
25 | This amendatory Act of the 96th General Assembly does not |
| |||||||
| |||||||
1 | in any way invalidate any agency executed or any act of any | ||||||
2 | agent done, or affect any claim, right, or remedy that accrued | ||||||
3 | prior to the effective date of this amendatory Act of the 96th | ||||||
4 | General Assembly. | ||||||
5 | (Source: P.A. 86-736.)
| ||||||
6 | (755 ILCS 45/3-3) (from Ch. 110 1/2, par. 803-3)
| ||||||
7 | Sec. 3-3. Statutory short form power of attorney for | ||||||
8 | property. The
following form may be known as "statutory | ||||||
9 | property power" and may be used
to grant an agent powers with | ||||||
10 | respect to property and financial matters.
When a power of | ||||||
11 | attorney in substantially the following form is used,
including | ||||||
12 | the "notice" paragraph at the beginning of the form on a | ||||||
13 | separate sheet in 14-point type in capital letters and
the | ||||||
14 | notarized form of acknowledgment at the end, it shall have the | ||||||
15 | meaning
and effect prescribed in this Act. Such a document | ||||||
16 | shall be deemed to be substantially the same format as the | ||||||
17 | statutory form if the explanatory language throughout the | ||||||
18 | document is distinguished in some way from the legal paragraphs | ||||||
19 | in the form, such as italicization or other difference in type | ||||||
20 | face or point size, if the "notice" paragraphs at the beginning | ||||||
21 | are not on a separate sheet of paper or are not in 14-point | ||||||
22 | type, or if the principal's initials do not appear in the | ||||||
23 | acknowledgement at the end of the "notice" paragraphs. The | ||||||
24 | validity of a power of attorney as
meeting the requirements of | ||||||
25 | a statutory property power shall not be
affected by the fact |
| |||||||
| |||||||
1 | that one or more of the categories of optional powers
listed in | ||||||
2 | the form are struck out or the form includes specific
| ||||||
3 | limitations on or additions to the agent's powers, as permitted | ||||||
4 | by the
form. Nothing in this Article shall invalidate or bar | ||||||
5 | use by the
principal of any other or different form of power of | ||||||
6 | attorney for property.
Nonstatutory property powers must be | ||||||
7 | executed by the principal and
designate the agent and the | ||||||
8 | agent's powers, but they need not be acknowledged
or
conform in | ||||||
9 | any other respect to the statutory property power.
| ||||||
10 | "NOTICE TO THE INDIVIDUAL SIGNING THE ILLINOIS | ||||||
11 | STATUTORY SHORT FORM POWER OF ATTORNEY FOR PROPERTY. | ||||||
12 | PLEASE READ THIS NOTICE CAREFULLY. The form that you will | ||||||
13 | be signing is a legal document. It is governed by the Illinois | ||||||
14 | Power of Attorney Act. If there is anything about this form | ||||||
15 | that you do not understand, you should ask a lawyer to explain | ||||||
16 | it to you. | ||||||
17 | The purpose of this Power of Attorney is to give your | ||||||
18 | designated "agent" broad powers to handle your financial | ||||||
19 | affairs, which may include the power to pledge, sell, or | ||||||
20 | dispose of any of your real or personal property, even without | ||||||
21 | your consent or any advance notice to you. You may name | ||||||
22 | successor agents under this form, but you may not name | ||||||
23 | co-agents. |
| |||||||
| |||||||
1 | This form does not impose a duty upon your agent to handle | ||||||
2 | your financial affairs, so it is important that you select an | ||||||
3 | agent who will agree to do this for you. It is also important | ||||||
4 | to select an agent whom you trust, since you are giving that | ||||||
5 | agent control over your financial assets and property. Any | ||||||
6 | agent who does act for you has a duty to use due care to act for | ||||||
7 | your benefit. He or she must also act in accordance with the | ||||||
8 | law and with the directions in this form. Your agent must keep | ||||||
9 | a record of all receipts, disbursements, and significant | ||||||
10 | actions taken as your agent. | ||||||
11 | Unless you specifically limit the period of time that this | ||||||
12 | Power of Attorney will be in effect, your agent may exercise | ||||||
13 | the powers given to him or her throughout your lifetime, both | ||||||
14 | before and after you become incapacitated. A court, however, | ||||||
15 | can take away the powers of your agent if it finds that the | ||||||
16 | agent is not acting properly. You may also revoke this Power of | ||||||
17 | Attorney if you wish. | ||||||
18 | The Powers you give your agent are explained more fully in | ||||||
19 | Section 3-4 of the Illinois "Statutory Short Form Power of | ||||||
20 | Attorney for Property Law". This form is a part of that law. | ||||||
21 | You are not required to sign this Power of Attorney. You | ||||||
22 | should not sign the Power of Attorney if you do not understand | ||||||
23 | everything in it, and what your agent will be able to do if you |
| |||||||
| |||||||
1 | do sign it. | ||||||
2 | Please place your initials on the following line indicating | ||||||
3 | that you have read this Notice: | ||||||
4 | ..................... | ||||||
5 | Principal's initials" | ||||||
6 | "ILLINOIS STATUTORY SHORT FORM POWER OF ATTORNEY FOR PROPERTY
| ||||||
7 | (NOTICE: THE PURPOSE OF THIS POWER OF ATTORNEY IS TO GIVE | ||||||
8 | THE PERSON YOU
DESIGNATE (YOUR "AGENT") BROAD POWERS TO HANDLE | ||||||
9 | YOUR PROPERTY, WHICH MAY
INCLUDE POWERS TO PLEDGE, SELL OR | ||||||
10 | OTHERWISE DISPOSE OF ANY REAL OR PERSONAL
PROPERTY WITHOUT | ||||||
11 | ADVANCE NOTICE TO YOU OR APPROVAL BY YOU. THIS FORM DOES
NOT | ||||||
12 | IMPOSE A DUTY ON YOUR AGENT TO EXERCISE GRANTED POWERS; BUT | ||||||
13 | WHEN POWERS
ARE EXERCISED, YOUR AGENT WILL HAVE TO USE DUE CARE | ||||||
14 | TO ACT FOR YOUR
BENEFIT AND IN ACCORDANCE WITH THIS FORM AND | ||||||
15 | KEEP A RECORD OF RECEIPTS,
DISBURSEMENTS AND SIGNIFICANT | ||||||
16 | ACTIONS TAKEN AS AGENT. A COURT CAN TAKE AWAY THE POWERS
OF | ||||||
17 | YOUR AGENT IF IT FINDS THE AGENT IS NOT ACTING PROPERLY. YOU | ||||||
18 | MAY NAME
SUCCESSOR AGENTS UNDER THIS FORM BUT NOT CO-AGENTS. | ||||||
19 | UNLESS YOU EXPRESSLY
LIMIT THE DURATION OF THIS POWER IN THE | ||||||
20 | MANNER PROVIDED BELOW, UNTIL YOU
REVOKE THIS POWER OR A COURT | ||||||
21 | ACTING ON YOUR BEHALF TERMINATES IT, YOUR
AGENT MAY EXERCISE | ||||||
22 | THE POWERS GIVEN HERE THROUGHOUT YOUR LIFETIME, EVEN
AFTER YOU | ||||||
23 | BECOME DISABLED. THE POWERS YOU GIVE YOUR AGENT ARE EXPLAINED
| ||||||
24 | MORE FULLY IN SECTION 3-4 OF THE ILLINOIS "STATUTORY SHORT FORM | ||||||
25 | POWER OF
ATTORNEY FOR PROPERTY LAW" OF WHICH THIS FORM IS A |
| |||||||
| |||||||
1 | PART
(SEE THE BACK OF THIS FORM). THAT LAW EXPRESSLY PERMITS | ||||||
2 | THE USE OF ANY
DIFFERENT FORM OF POWER OF ATTORNEY YOU MAY | ||||||
3 | DESIRE. IF THERE IS ANYTHING
ABOUT THIS FORM THAT YOU DO NOT | ||||||
4 | UNDERSTAND, YOU SHOULD ASK A LAWYER TO EXPLAIN
IT TO YOU.)
| ||||||
5 | POWER OF ATTORNEY made this .... day of ....... (month) | ||||||
6 | ...... (year)
| ||||||
7 | 1. I, ..............., (insert name and address of | ||||||
8 | principal)
hereby appoint:
| ||||||
9 | .............................................................
| ||||||
10 | (insert name and address of agent)
| ||||||
11 | as my attorney-in-fact (my "agent") to act for me and in my | ||||||
12 | name (in any
way I could act in person) with respect to the | ||||||
13 | following powers, as defined
in Section 3-4 of the "Statutory | ||||||
14 | Short Form Power of Attorney for Property Law"
(including all | ||||||
15 | amendments), but subject to any limitations on or additions
to | ||||||
16 | the specified powers inserted in paragraph 2 or 3 below:
| ||||||
17 | (YOU MUST STRIKE OUT ANY ONE OR MORE OF THE FOLLOWING | ||||||
18 | CATEGORIES OF
POWERS YOU DO NOT WANT YOUR AGENT TO HAVE. | ||||||
19 | FAILURE TO STRIKE THE TITLE
OF ANY CATEGORY WILL CAUSE THE | ||||||
20 | POWERS DESCRIBED IN THAT CATEGORY TO BE
GRANTED TO THE AGENT. | ||||||
21 | TO STRIKE OUT A CATEGORY YOU MUST DRAW A LINE
THROUGH THE TITLE | ||||||
22 | OF THAT CATEGORY.)
| ||||||
23 | (a) Real estate transactions.
| ||||||
24 | (b) Financial institution transactions.
| ||||||
25 | (c) Stock and bond transactions.
|
| |||||||
| |||||||
1 | (d) Tangible personal property transactions.
| ||||||
2 | (e) Safe deposit box transactions.
| ||||||
3 | (f) Insurance and annuity transactions.
| ||||||
4 | (g) Retirement plan transactions.
| ||||||
5 | (h) Social Security, employment and military service | ||||||
6 | benefits.
| ||||||
7 | (i) Tax matters.
| ||||||
8 | (j) Claims and litigation.
| ||||||
9 | (k) Commodity and option transactions.
| ||||||
10 | (l) Business operations.
| ||||||
11 | (m) Borrowing transactions.
| ||||||
12 | (n) Estate transactions.
| ||||||
13 | (o) All other property powers and transactions.
| ||||||
14 | (LIMITATIONS ON AND ADDITIONS TO THE AGENT'S POWERS MAY BE | ||||||
15 | INCLUDED IN THIS
POWER OF ATTORNEY IF THEY ARE SPECIFICALLY | ||||||
16 | DESCRIBED BELOW.)
| ||||||
17 | 2. The powers granted above shall not include the following | ||||||
18 | powers or
shall be modified or limited in the following | ||||||
19 | particulars (here you may
include any specific limitations you | ||||||
20 | deem appropriate, such as a
prohibition or conditions on the | ||||||
21 | sale of particular stock or real estate or
special rules on | ||||||
22 | borrowing by the agent):
| ||||||
23 | .............................................................
| ||||||
24 | .............................................................
| ||||||
25 | .............................................................
| ||||||
26 | .............................................................
|
| |||||||
| |||||||
1 | .............................................................
| ||||||
2 | 3. In addition to the powers granted above, I grant my | ||||||
3 | agent the
following powers (here you may add any other | ||||||
4 | delegable powers including,
without limitation, power to make | ||||||
5 | gifts, exercise powers of appointment,
name or change | ||||||
6 | beneficiaries or joint tenants or revoke or amend any trust
| ||||||
7 | specifically referred to below):
| ||||||
8 | .............................................................
| ||||||
9 | .............................................................
| ||||||
10 | .............................................................
| ||||||
11 | .............................................................
| ||||||
12 | .............................................................
| ||||||
13 | (YOUR AGENT WILL HAVE AUTHORITY TO EMPLOY OTHER PERSONS AS | ||||||
14 | NECESSARY TO
ENABLE THE AGENT TO PROPERLY EXERCISE THE POWERS | ||||||
15 | GRANTED IN THIS FORM, BUT
YOUR AGENT WILL HAVE TO MAKE ALL | ||||||
16 | DISCRETIONARY DECISIONS. IF YOU WANT TO
GIVE YOUR AGENT THE | ||||||
17 | RIGHT TO DELEGATE DISCRETIONARY DECISION-MAKING POWERS
TO | ||||||
18 | OTHERS, YOU SHOULD KEEP THE NEXT SENTENCE, OTHERWISE IT SHOULD | ||||||
19 | BE STRUCK OUT.)
| ||||||
20 | 4. My agent shall have the right by written instrument to | ||||||
21 | delegate any
or all of the foregoing powers involving | ||||||
22 | discretionary decision-making to
any person or persons whom my | ||||||
23 | agent may select, but such delegation may be
amended or revoked | ||||||
24 | by any agent (including any successor) named by me who
is | ||||||
25 | acting under this power of attorney at the time of reference.
| ||||||
26 | (YOUR AGENT WILL BE ENTITLED TO REIMBURSEMENT FOR ALL |
| |||||||
| |||||||
1 | REASONABLE EXPENSES
INCURRED IN ACTING UNDER THIS POWER OF | ||||||
2 | ATTORNEY. STRIKE OUT THE NEXT
SENTENCE IF YOU DO NOT WANT YOUR | ||||||
3 | AGENT TO ALSO BE ENTITLED TO REASONABLE
COMPENSATION FOR | ||||||
4 | SERVICES AS AGENT.)
| ||||||
5 | 5. My agent shall be entitled to reasonable compensation | ||||||
6 | for services
rendered as agent under this power of attorney.
| ||||||
7 | (THIS POWER OF ATTORNEY MAY BE AMENDED OR REVOKED BY YOU AT ANY | ||||||
8 | TIME AND IN
ANY MANNER. ABSENT AMENDMENT OR REVOCATION, THE | ||||||
9 | AUTHORITY GRANTED IN THIS
POWER OF ATTORNEY WILL BECOME | ||||||
10 | EFFECTIVE AT THE TIME THIS POWER IS SIGNED
AND WILL CONTINUE | ||||||
11 | UNTIL YOUR DEATH UNLESS A LIMITATION ON THE BEGINNING
DATE OR | ||||||
12 | DURATION IS MADE BY INITIALING AND COMPLETING EITHER (OR BOTH) | ||||||
13 | OF
THE FOLLOWING:)
| ||||||
14 | 6. ( ) This power of attorney shall become effective on
| ||||||
15 | .............................................................
| ||||||
16 | (insert a future date or event during your lifetime, such as | ||||||
17 | court
determination of your disability, when you want this | ||||||
18 | power to first take effect)
| ||||||
19 | 7. ( ) This power of attorney shall terminate on
| ||||||
20 | .............................................................
| ||||||
21 | (insert a future date or event, such as court determination of | ||||||
22 | your
disability, when you want this power to terminate prior to | ||||||
23 | your death)
| ||||||
24 | (IF YOU WISH TO NAME SUCCESSOR AGENTS, INSERT THE NAME(S) AND | ||||||
25 | ADDRESS(ES)
OF SUCH SUCCESSOR(S) IN THE FOLLOWING PARAGRAPH.)
| ||||||
26 | 8. If any agent named by me shall die, become incompetent, |
| |||||||
| |||||||
1 | resign
or refuse to accept the office of agent, I name the | ||||||
2 | following
(each to act alone and successively,
in the order | ||||||
3 | named) as successor(s) to such agent:
| ||||||
4 | .............................................................
| ||||||
5 | .............................................................
| ||||||
6 | For purposes of this paragraph 8, a person shall be considered | ||||||
7 | to be
incompetent if and while the person is a minor or an | ||||||
8 | adjudicated
incompetent or disabled person or the person is | ||||||
9 | unable to give prompt and
intelligent consideration to business | ||||||
10 | matters, as certified by a licensed physician.
(IF YOU WISH TO | ||||||
11 | NAME YOUR AGENT AS
GUARDIAN OF YOUR ESTATE, IN THE EVENT A | ||||||
12 | COURT DECIDES THAT ONE
SHOULD BE APPOINTED, YOU
MAY, BUT ARE | ||||||
13 | NOT REQUIRED TO, DO SO BY RETAINING THE FOLLOWING PARAGRAPH.
| ||||||
14 | THE COURT
WILL APPOINT YOUR AGENT IF THE COURT FINDS THAT SUCH | ||||||
15 | APPOINTMENT WILL SERVE YOUR
BEST INTERESTS AND WELFARE. STRIKE | ||||||
16 | OUT PARAGRAPH 9 IF YOU DO NOT WANT
YOUR AGENT TO ACT AS | ||||||
17 | GUARDIAN.)
| ||||||
18 | 9. If a guardian of my estate (my property) is to be | ||||||
19 | appointed, I
nominate the agent acting under this power of | ||||||
20 | attorney as such guardian,
to serve without bond or security.
| ||||||
21 | 10. I am fully informed as to all the contents of this form | ||||||
22 | and
understand the full import of this grant of powers to my | ||||||
23 | agent.
| ||||||
24 | Signed ..................................................
| ||||||
25 | (principal)
| ||||||
26 | (YOU MAY, BUT ARE NOT REQUIRED TO, REQUEST YOUR AGENT AND |
| |||||||
| |||||||
1 | SUCCESSOR
AGENTS TO PROVIDE SPECIMEN SIGNATURES BELOW. IF YOU | ||||||
2 | INCLUDE SPECIMEN
SIGNATURES IN THIS POWER OF ATTORNEY, YOU MUST | ||||||
3 | COMPLETE THE CERTIFICATION
OPPOSITE THE SIGNATURES OF THE | ||||||
4 | AGENTS.)
| ||||||
5 | Specimen signatures of I certify that the signatures
| ||||||
6 | agent (and successors) of my agent (and successors)
| ||||||
7 | are correct.
| ||||||
8 | .......................... .............................
| ||||||
9 | (agent) (principal)
| ||||||
10 | .......................... .............................
| ||||||
11 | (successor agent) (principal)
| ||||||
12 | .......................... .............................
| ||||||
13 | (successor agent) (principal)
| ||||||
14 | (THIS POWER OF ATTORNEY WILL NOT BE EFFECTIVE UNLESS IT IS | ||||||
15 | NOTARIZED AND
SIGNED BY AT LEAST ONE ADDITIONAL WITNESS,
USING | ||||||
16 | THE FORM BELOW.)
| ||||||
17 | State of ............)
| ||||||
18 | ) SS.
| ||||||
19 | County of ...........)
| ||||||
20 | The undersigned, a notary public in and for the above | ||||||
21 | county and state,
certifies that ......................., | ||||||
22 | known to me to be the same person
whose name is subscribed as | ||||||
23 | principal to the foregoing power of attorney,
appeared before | ||||||
24 | me and the additional witness in person and acknowledged
| ||||||
25 | signing and delivering the
instrument as the free and voluntary | ||||||
26 | act of the principal, for the uses and
purposes therein set |
| |||||||
| |||||||
1 | forth (, and certified to the correctness of the
signature(s) | ||||||
2 | of the agent(s)).
| ||||||
3 | Dated: ................ (SEAL)
| ||||||
4 | ..............................
| ||||||
5 | Notary Public
| ||||||
6 | My commission expires .................
| ||||||
7 | The undersigned witness certifies that ................, known | ||||||
8 | to me to be
the same person whose name is subscribed as | ||||||
9 | principal to the foregoing power of
attorney, appeared before | ||||||
10 | me and the notary public and acknowledged signing and
| ||||||
11 | delivering the instrument as the free and voluntary act of the | ||||||
12 | principal, for
the
uses and purposes therein set forth. I | ||||||
13 | believe him or her to be of sound mind
and memory.
| ||||||
14 | Dated: ................ (SEAL)
| ||||||
15 | ..............................
| ||||||
16 | Witness
| ||||||
17 | (THE NAME , AND ADDRESS , AND PHONE NUMBER OF THE PERSON | ||||||
18 | PREPARING THIS FORM OR WHO ASSISTED THE PRINCIPAL IN COMPLETING | ||||||
19 | THIS FORM SHOULD BE INSERTED BELOW SHOULD BE
INSERTED
IF THE | ||||||
20 | AGENT WILL HAVE POWER TO CONVEY ANY INTEREST IN REAL ESTATE .)
| ||||||
21 | .................... | ||||||
22 | (Name) | ||||||
23 | .................... | ||||||
24 | (Address) | ||||||
25 | .................... | ||||||
26 | (Phone) |
| |||||||
| |||||||
1 | This document was prepared by:
| ||||||
2 | .............................................................
| ||||||
3 | ............................................................."
| ||||||
4 | The requirement of the signature of an additional
witness | ||||||
5 | imposed by this amendatory Act of the 91st General
Assembly | ||||||
6 | applies only to instruments executed on or after
the effective | ||||||
7 | date of this amendatory Act of the 91st
General Assembly.
| ||||||
8 | (Source: P.A. 91-790, eff. 6-9-00 .)
| ||||||
9 | (755 ILCS 45/3-3.5 new) | ||||||
10 | Sec. 3-3.5. Notice to agent. The following form may be | ||||||
11 | known as "notice to agent" and may be supplied to an agent | ||||||
12 | appointed under a power of attorney for property. | ||||||
13 | "IMPORTANT INFORMATION FOR AGENT | ||||||
14 | When you accept the authority granted under this power of | ||||||
15 | attorney a special legal relationship, known as agency, is | ||||||
16 | created between you and the principal. Agency imposes upon you | ||||||
17 | duties that continue until you resign or the power of attorney | ||||||
18 | is terminated or revoked. | ||||||
19 | As agent you must: | ||||||
20 | (1) do what you know the principal reasonably expects you | ||||||
21 | to do with the principal's property; | ||||||
22 | (2) act in good faith with care, competence, and diligence | ||||||
23 | for the best interest of the principal; | ||||||
24 | (3) keep a complete record of all receipts, disbursements | ||||||
25 | and transactions conducted for the principal; and |
| |||||||
| |||||||
1 | (4) preserve the principal's estate plan to the extent you | ||||||
2 | know the plan, unless preserving the estate plan is | ||||||
3 | inconsistent with the principal's best interest. | ||||||
4 | As agent you must not: | ||||||
5 | (1) engage in conflicts that would impair your ability to | ||||||
6 | act in the principal's best interest; | ||||||
7 | (2) do any act beyond the authority granted in this power | ||||||
8 | of attorney; | ||||||
9 | (3) commingle the principal's funds with your funds; | ||||||
10 | (4) borrow funds or other property from the principal, | ||||||
11 | unless otherwise authorized; and | ||||||
12 | (5) continue acting on behalf of the principal if you learn | ||||||
13 | of any event which terminates this power of attorney or your | ||||||
14 | authority under this power of attorney. | ||||||
15 | If you have special skills or expertise, you must use those | ||||||
16 | special skills and expertise when acting for the principal. You | ||||||
17 | must disclose your identity as an agent whenever you act for | ||||||
18 | the principal by writing or printing the name of the principal | ||||||
19 | and signing your own name as "agent" in the following manner: | ||||||
20 | "(Principal's Name) by (Your Name) as Agent" | ||||||
21 | The meaning of the powers granted to you is contained in | ||||||
22 | the "Explanation of the powers granted in the statutory short | ||||||
23 | form power of attorney for property" attached to the Illinois | ||||||
24 | Short Form Power of Attorney for Property and in the body of | ||||||
25 | the power of attorney for property document. | ||||||
26 | If you violate your duties as agent or act outside the |
| |||||||
| |||||||
1 | authority granted to you, you may be liable for any damages, | ||||||
2 | including attorney's fees and costs, caused by your violation." | ||||||
3 | (755 ILCS 45/3-3.6 new) | ||||||
4 | Sec. 3-3.6. Limitations on who may witness property powers. | ||||||
5 | Every property power shall bear the signatures of 2 witnesses | ||||||
6 | to the signing of the agency. None of the following may serve | ||||||
7 | as a witness to the signing of a property power: | ||||||
8 | (a) the attending physician or mental health service | ||||||
9 | provider or relative of the physician or provider; | ||||||
10 | (b) an owner, operator, or relative of an owner or operator | ||||||
11 | of a health care facility in which the principal is a patient | ||||||
12 | or resident; | ||||||
13 | (c) a parent, sibling, descendant, or any spouse of such | ||||||
14 | parent, sibling, or descendant of either the principal or any | ||||||
15 | agent or successor agent, whether such relationship is by | ||||||
16 | blood, marriage, or adoption; or | ||||||
17 | (d) any agent or successor agent. | ||||||
18 | (755 ILCS 45/4-5.1 new) | ||||||
19 | Sec. 4-5.1. Limitations on who may witness health care | ||||||
20 | agencies. Every health care agency shall bear the signatures of | ||||||
21 | 2 witnesses to the signing of the agency. None of the following | ||||||
22 | may serve as a witness to the signing of a health care agency: | ||||||
23 | (a) the attending physician or mental health service | ||||||
24 | provider or relative of the physician or provider; |
| |||||||
| |||||||
1 | (b) an owner, operator, or relative of an owner or operator | ||||||
2 | of a health care facility in which the principal is a patient | ||||||
3 | or resident; | ||||||
4 | (c) a parent, sibling, descendant, or any spouse of such | ||||||
5 | parent, sibling, or descendant of either the principal or any | ||||||
6 | agent or successor agent, whether such relationship is by | ||||||
7 | blood, marriage, or adoption; or | ||||||
8 | (d) any agent or successor agent.
| ||||||
9 | (755 ILCS 45/4-10) (from Ch. 110 1/2, par. 804-10)
| ||||||
10 | Sec. 4-10. Statutory short form power of attorney for | ||||||
11 | health care.
| ||||||
12 | (a) The following form (sometimes also referred to in this | ||||||
13 | Act as the
"statutory health care power") may be used to grant | ||||||
14 | an agent powers with
respect to the principal's own health | ||||||
15 | care; but the statutory health care
power is not intended to be | ||||||
16 | exclusive nor to cover delegation of a parent's
power to | ||||||
17 | control the health care of a minor child, and no provision of | ||||||
18 | this
Article shall be construed to invalidate or bar use by the | ||||||
19 | principal of any
other or
different form of power of attorney | ||||||
20 | for health care. Nonstatutory health
care powers must be
| ||||||
21 | executed by the principal, designate the agent and the agent's | ||||||
22 | powers, and
comply with Section 4-5 of this Article, but they | ||||||
23 | need not be witnessed or
conform in any other respect to the | ||||||
24 | statutory health care power. When a
power of attorney in | ||||||
25 | substantially the
following form is used, including the |
| |||||||
| |||||||
1 | "notice" paragraph at the beginning of the form on a separate | ||||||
2 | sheet in 14-point type
in capital letters , it shall have the | ||||||
3 | meaning and effect prescribed in this
Act. Such a document | ||||||
4 | shall be deemed to be in substantially the same format as the | ||||||
5 | statutory form if the explanatory language throughout the | ||||||
6 | document is distinguished in some way from the legal paragraphs | ||||||
7 | in the form, such as italicization or other difference in type | ||||||
8 | face or point size, if the "notice" paragraphs are not on a | ||||||
9 | separate sheet or not in 14-point type, or if the principal's | ||||||
10 | initials do not appear on the acknowledgment at the end of the | ||||||
11 | "notice" paragraphs. The statutory health care power may be | ||||||
12 | included in or
combined with any
other form of power of | ||||||
13 | attorney governing property or other matters.
| ||||||
14 | NOTICE TO THE INDIVIDUAL SIGNING | ||||||
15 | THE ILLINOIS STATUTORY | ||||||
16 | SHORT FORM POWER OF ATTORNEY FOR HEALTH CARE | ||||||
17 | PLEASE READ THIS NOTICE CAREFULLY. The form that you will | ||||||
18 | be signing is a legal document. It is governed by the Illinois | ||||||
19 | Power of Attorney Act. If there is anything about this form | ||||||
20 | that you do not understand, you should ask a lawyer to explain | ||||||
21 | it to you. | ||||||
22 | The purpose of this Power of Attorney is to give your | ||||||
23 | designated "agent" broad powers to make health care decisions | ||||||
24 | for you, including the power to require, consent to, or | ||||||
25 | withdraw treatment for any physical or mental condition, and to | ||||||
26 | admit you or discharge you from any hospital, home, or other |
| |||||||
| |||||||
1 | institution. You may name successor agents under this form, but | ||||||
2 | you may not name co-agents. | ||||||
3 | This form does not impose a duty upon your agent to make | ||||||
4 | such health care decisions, so it is important that you select | ||||||
5 | an agent who will agree to do this for you and who will make | ||||||
6 | those decisions as you would wish. It is also important to | ||||||
7 | select an agent whom you trust, since you are giving that agent | ||||||
8 | control over your medical decision-making, including | ||||||
9 | end-of-life decisions. Any agent who does act for you has a | ||||||
10 | duty to use due care to act for your benefit. He or she must | ||||||
11 | also act in accordance with the law and with the directions in | ||||||
12 | this form. Your agent must keep a record of all significant | ||||||
13 | actions taken as your agent. | ||||||
14 | Unless you specifically limit the period of time that this | ||||||
15 | Power of Attorney will be in effect, your agent may exercise | ||||||
16 | the powers given to him or her throughout your lifetime, even | ||||||
17 | after you become disabled. A court, however, can take away the | ||||||
18 | powers of your agent if it finds that the agent is not acting | ||||||
19 | properly. You may also revoke this Power of Attorney if you | ||||||
20 | wish. | ||||||
21 | The Powers you give your agent, your right to revoke those | ||||||
22 | powers, and the penalties for violating the law are explained | ||||||
23 | more fully in Sections 4-5, 4-6 and 4-10(b) of the Illinois | ||||||
24 | Power of Attorney Act. This form is a part of that law. | ||||||
25 | You are not required to sign the Power of Attorney. You | ||||||
26 | should not sign it if you do not understand everything in it, |
| |||||||
| |||||||
1 | and what your agent will be able to do if you do sign it. | ||||||
2 | Please put your initials on the following line indicating | ||||||
3 | that you have read this Notice: | ||||||
4 | ...................... | ||||||
5 | (Principal's initials)" | ||||||
6 | "ILLINOIS STATUTORY SHORT FORM POWER OF ATTORNEY FOR HEALTH | ||||||
7 | CARE
| ||||||
8 | (NOTICE: THE PURPOSE OF THIS POWER OF ATTORNEY IS TO GIVE | ||||||
9 | THE PERSON YOU
DESIGNATE (YOUR "AGENT") BROAD POWERS TO MAKE | ||||||
10 | HEALTH CARE DECISIONS FOR YOU,
INCLUDING POWER TO REQUIRE, | ||||||
11 | CONSENT TO OR WITHDRAW ANY TYPE OF PERSONAL
CARE OR MEDICAL | ||||||
12 | TREATMENT FOR ANY PHYSICAL OR MENTAL CONDITION AND TO ADMIT
YOU | ||||||
13 | TO OR DISCHARGE YOU FROM ANY HOSPITAL, HOME OR OTHER | ||||||
14 | INSTITUTION. THIS
FORM DOES NOT IMPOSE A DUTY ON YOUR AGENT TO | ||||||
15 | EXERCISE GRANTED POWERS; BUT
WHEN POWERS ARE EXERCISED, YOUR | ||||||
16 | AGENT WILL HAVE TO USE
DUE CARE TO ACT FOR
YOUR BENEFIT AND IN | ||||||
17 | ACCORDANCE WITH THIS FORM AND KEEP A RECORD OF
RECEIPTS, | ||||||
18 | DISBURSEMENTS AND SIGNIFICANT ACTIONS TAKEN AS AGENT. A COURT
| ||||||
19 | CAN TAKE AWAY THE
POWERS OF YOUR AGENT IF IT FINDS THE AGENT IS | ||||||
20 | NOT ACTING PROPERLY. YOU MAY
NAME SUCCESSOR AGENTS UNDER THIS | ||||||
21 | FORM
BUT NOT CO-AGENTS, AND NO HEALTH CARE PROVIDER MAY BE | ||||||
22 | NAMED. UNLESS
YOU EXPRESSLY LIMIT THE DURATION OF THIS POWER
IN | ||||||
23 | THE MANNER PROVIDED BELOW, UNTIL YOU REVOKE THIS POWER OR A | ||||||
24 | COURT ACTING
ON YOUR BEHALF TERMINATES IT, YOUR AGENT MAY | ||||||
25 | EXERCISE THE POWERS GIVEN HERE
THROUGHOUT YOUR LIFETIME, EVEN | ||||||
26 | AFTER YOU BECOME DISABLED. THE POWERS YOU
GIVE YOUR AGENT, YOUR |
| |||||||
| |||||||
1 | RIGHT TO REVOKE THOSE POWERS AND THE PENALTIES FOR
VIOLATING | ||||||
2 | THE LAW ARE EXPLAINED MORE FULLY IN SECTIONS 4-5, 4-6, 4-9 AND
| ||||||
3 | 4-10(b) OF THE ILLINOIS
"POWERS OF ATTORNEY FOR HEALTH CARE | ||||||
4 | LAW"
OF WHICH THIS FORM IS A PART (SEE THE BACK OF THIS FORM). | ||||||
5 | THAT LAW
EXPRESSLY PERMITS THE USE OF ANY DIFFERENT FORM OF | ||||||
6 | POWER OF ATTORNEY YOU
MAY DESIRE. IF THERE IS ANYTHING ABOUT | ||||||
7 | THIS FORM THAT YOU DO NOT
UNDERSTAND, YOU SHOULD ASK A LAWYER | ||||||
8 | TO EXPLAIN IT TO YOU.)
| ||||||
9 | POWER OF ATTORNEY made this .......................day of
| ||||||
10 | ................................
| ||||||
11 | (month) (year)
| ||||||
12 | 1. I, ..................................................,
| ||||||
13 | (insert name and address of principal)
| ||||||
14 | hereby appoint:
| ||||||
15 | ............................................................
| ||||||
16 | (insert name and address of agent)
| ||||||
17 | as my attorney-in-fact (my "agent") to act for me and in my | ||||||
18 | name (in any
way I could act in person) to make any and all | ||||||
19 | decisions for me concerning
my personal care, medical | ||||||
20 | treatment, hospitalization and health care and to
require, | ||||||
21 | withhold or withdraw any type of medical treatment or | ||||||
22 | procedure,
even though my death may ensue. | ||||||
23 | In the event that my agent fails or refuses to act, then my | ||||||
24 | medical provider shall be governed by my Living Will. | ||||||
25 | A. My agent shall have the same access to my
medical | ||||||
26 | records that I have, including the right to disclose the |
| |||||||
| |||||||
1 | contents
to others. My agent shall also have full power to
| ||||||
2 | authorize an autopsy and direct the disposition of my remains. | ||||||
3 | B.
Effective upon my death, my agent has the full power to | ||||||
4 | make an anatomical
gift of the following ( Initial initial one . | ||||||
5 | In the event none of the options are initialed, then it shall | ||||||
6 | be concluded that I do not wish to grant my agent any such | ||||||
7 | authority. ):
| ||||||
8 | ....Any organs, tissues, or eyes suitable for | ||||||
9 | transplantation or used for
research or education.
| ||||||
10 | ....Specific organs: .................................
| ||||||
11 | ....I do not grant my agent authority to make any | ||||||
12 | anatomical gifts. | ||||||
13 | C. My agent shall also have full power to authorize an | ||||||
14 | autopsy and direct the disposition of my remains. I intend for | ||||||
15 | this power of attorney to be in substantial compliance with | ||||||
16 | Section 10 of the Disposition of Remains Act, 755 ILCS 65/1 et | ||||||
17 | seq. All decisions made by my agent with respect to the | ||||||
18 | disposition of my remains, including cremation, shall be | ||||||
19 | binding. I hereby direct any cemetery organization, business | ||||||
20 | operating a crematory or columbarium or both, funeral director | ||||||
21 | or embalmer, or funeral establishment who receives a copy of | ||||||
22 | this document to act under it. | ||||||
23 | I intend for the person named as my agent to be treated as | ||||||
24 | I would be with respect to my rights regarding the use and | ||||||
25 | disclosure of my individually identifiable health information | ||||||
26 | or other medical records, including records or communications |
| |||||||
| |||||||
1 | governed by the Mental Health and Developmental Disabilities | ||||||
2 | Confidentiality Act. This release authority applies to any | ||||||
3 | information governed by the Health Insurance Portability and | ||||||
4 | Accountability Act of 1996 ("HIPAA") and regulations | ||||||
5 | thereunder. I intend for the person named as my agent to serve | ||||||
6 | as my "personal representative" as that term is defined under | ||||||
7 | HIPAA and regulations thereunder. The person named as my agent | ||||||
8 | shall have the power to authorize the release of information | ||||||
9 | governed by HIPAA to third parties. I authorize: | ||||||
10 | any physician, health care professional, dentist, | ||||||
11 | health plan, hospital, clinic, laboratory, pharmacy or | ||||||
12 | other covered health care provider, any insurance company | ||||||
13 | and the Medical Informational Bureau, Inc., or any other | ||||||
14 | health care clearinghouse that has provided treatment or | ||||||
15 | services to me, or that has paid for or is seeking payment | ||||||
16 | for me for such services, | ||||||
17 | to give, disclose, and release to the person named as my agent, | ||||||
18 | without restriction, all of my individually identifiable | ||||||
19 | health information and medical records, regarding any past, | ||||||
20 | present, or future medical or mental health condition, | ||||||
21 | including all information relating to the diagnosis and | ||||||
22 | treatment of HIV/AIDS, sexually transmitted diseases, drug or | ||||||
23 | alcohol abuse, and mental illness (including records or | ||||||
24 | communications governed by the Mental Health and Developmental | ||||||
25 | Disabilities Confidentiality Act.) | ||||||
26 | The authority given to the person named as my agent shall |
| |||||||
| |||||||
1 | supersede any prior agreement that I may have with my health | ||||||
2 | care providers to restrict access to, or disclosure of, my | ||||||
3 | individually identifiable health information. The authority | ||||||
4 | given to the person named as my agent has no expiration date | ||||||
5 | and shall expire only in the event that I revoke the authority | ||||||
6 | in writing and deliver it to my health care provider. The | ||||||
7 | authority given to the person named as my agent to serve as my | ||||||
8 | "personal representative" as defined under HIPAA and | ||||||
9 | regulations thereunder and to access my individually | ||||||
10 | identifiable health information or authorize the release of the | ||||||
11 | same to third parties shall take effect immediately, even if I | ||||||
12 | designate in Paragraph 3 of this document that this agency | ||||||
13 | shall otherwise take effect at some future date. | ||||||
14 | (THE ABOVE GRANT OF POWER IS INTENDED TO BE AS BROAD AS | ||||||
15 | POSSIBLE SO THAT
YOUR AGENT WILL HAVE AUTHORITY TO MAKE ANY | ||||||
16 | DECISION YOU COULD MAKE TO
OBTAIN OR TERMINATE ANY TYPE OF | ||||||
17 | HEALTH CARE, INCLUDING WITHDRAWAL OF FOOD
AND WATER AND OTHER | ||||||
18 | LIFE-SUSTAINING MEASURES, IF YOUR AGENT BELIEVES SUCH
ACTION | ||||||
19 | WOULD BE CONSISTENT WITH YOUR INTENT AND DESIRES. IF YOU WISH | ||||||
20 | TO
LIMIT THE SCOPE OF YOUR AGENT'S POWERS OR PRESCRIBE SPECIAL | ||||||
21 | RULES OR LIMIT
THE POWER TO MAKE AN ANATOMICAL GIFT, AUTHORIZE | ||||||
22 | AUTOPSY OR DISPOSE OF
REMAINS, YOU MAY DO SO IN THE FOLLOWING | ||||||
23 | PARAGRAPHS.)
| ||||||
24 | 2. The powers granted above shall not include the following | ||||||
25 | powers or
shall be subject to the following rules or | ||||||
26 | limitations (here you may include
any specific limitations you |
| |||||||
| |||||||
1 | deem appropriate, such as: your own
definition of when | ||||||
2 | life-sustaining measures should be withheld; a direction
to | ||||||
3 | continue food and fluids or life-sustaining treatment in
all | ||||||
4 | events; or instructions to refuse
any specific types of | ||||||
5 | treatment that are inconsistent with your religious
beliefs or | ||||||
6 | unacceptable to you for any other reason, such as blood
| ||||||
7 | transfusion, electro-convulsive therapy, amputation, | ||||||
8 | psychosurgery,
voluntary admission to a mental institution, | ||||||
9 | etc.):
| ||||||
10 | .............................................................
| ||||||
11 | .............................................................
| ||||||
12 | .............................................................
| ||||||
13 | .............................................................
| ||||||
14 | .............................................................
| ||||||
15 | (THE SUBJECT OF LIFE-SUSTAINING TREATMENT IS OF PARTICULAR | ||||||
16 | IMPORTANCE. FOR
YOUR CONVENIENCE IN DEALING WITH THAT SUBJECT, | ||||||
17 | SOME GENERAL STATEMENTS
CONCERNING THE WITHHOLDING OR REMOVAL | ||||||
18 | OF LIFE-SUSTAINING TREATMENT ARE SET
FORTH BELOW. IF YOU AGREE | ||||||
19 | WITH ONE OF THESE STATEMENTS, YOU MAY
INITIAL THAT STATEMENT; | ||||||
20 | BUT DO NOT INITIAL MORE THAN ONE):
| ||||||
21 | I do not want my life to be prolonged nor do I want | ||||||
22 | life-sustaining
treatment to be provided or continued if my | ||||||
23 | agent believes the burdens of
the treatment outweigh the | ||||||
24 | expected benefits. I want my agent to consider
the relief of | ||||||
25 | suffering, the expense involved and the quality as well as
the | ||||||
26 | possible extension of my life in making decisions concerning
|
| |||||||
| |||||||
1 | life-sustaining treatment.
| ||||||
2 | Initialed...........................
| ||||||
3 | I want my life to be prolonged and I want life-sustaining | ||||||
4 | treatment to be
provided or continued unless I am in a coma | ||||||
5 | which my attending physician
believes to be irreversible , in | ||||||
6 | the opinion of my attending physician, in accordance with | ||||||
7 | reasonable medical
standards at the time of reference , in a | ||||||
8 | state of "permanent unconsciousness" . If and when I am in a | ||||||
9 | state of "permanent unconsciousness" I have suffered
| ||||||
10 | irreversible coma , I want life-sustaining treatment to be | ||||||
11 | withheld or
discontinued. For purposes of this Section, | ||||||
12 | "permanent unconsciousness" shall mean a condition that, to a | ||||||
13 | high degree of medical certainty, (i) will last permanently, | ||||||
14 | without improvement, (ii) in which thought, sensation, | ||||||
15 | purposeful action, social interaction, and awareness of self | ||||||
16 | and environment are absent, and (iii) for which initiating or | ||||||
17 | continuing life sustaining treatment, in light of my medical | ||||||
18 | condition, provides only minimal medical benefit.
| ||||||
19 | Initialed...........................
| ||||||
20 | I want my life to be prolonged to the greatest extent | ||||||
21 | possible without
regard to my condition, the chances I have for | ||||||
22 | recovery or the cost of the
procedures.
| ||||||
23 | Initialed...........................
| ||||||
24 | (THIS POWER OF ATTORNEY MAY BE AMENDED OR REVOKED BY YOU IN THE | ||||||
25 | MANNER
PROVIDED IN SECTION 4-6 OF THE ILLINOIS "POWERS OF | ||||||
26 | ATTORNEY FOR HEALTH CARE
LAW" (SEE THE BACK OF THIS FORM). YOUR |
| |||||||
| |||||||
1 | AGENT CAN ACT IMMEDIATELY UNLESS YOU SPECIFY OTHERWISE. ABSENT | ||||||
2 | AMENDMENT OR
REVOCATION, THE AUTHORITY GRANTED IN THIS
POWER OF | ||||||
3 | ATTORNEY WILL BECOME EFFECTIVE AT THE TIME THIS POWER IS SIGNED
| ||||||
4 | AND WILL CONTINUE UNTIL YOUR DEATH, AND BEYOND IF ANATOMICAL | ||||||
5 | GIFT, AUTOPSY
OR DISPOSITION OF REMAINS IS AUTHORIZED, UNLESS A | ||||||
6 | LIMITATION ON THE
BEGINNING DATE OR DURATION IS MADE BY | ||||||
7 | INITIALING AND COMPLETING EITHER OR
BOTH OF THE FOLLOWING: )
| ||||||
8 | 3. ( ) This power of attorney shall become effective on
| ||||||
9 | .............................................................
| ||||||
10 | .............................................................
| ||||||
11 | (insert a future date or event during your lifetime, such as | ||||||
12 | court
determination of your disability, when you want this | ||||||
13 | power to first take
effect)
| ||||||
14 | (IF YOU DO NOT AMEND OR REVOKE THIS POWER, OR IF YOU DO NOT | ||||||
15 | SPECIFY A SPECIFIC ENDING DATE IN SECTION 4, IT WILL REMAIN IN | ||||||
16 | EFFECT UNTIL YOUR DEATH, EXCEPT THAT YOUR AGENT WILL STILL HAVE | ||||||
17 | THE AUTHORITY TO DONATE YOUR ORGANS, AUTHORIZE AN AUTOPSY, AND | ||||||
18 | DISPOSE OF YOUR REMAINS AFTER YOUR DEATH, IF YOU GRANT THAT | ||||||
19 | AUTHORITY TO YOUR AGENT.) | ||||||
20 | 4. ( ) This power of attorney shall terminate on
.......
| ||||||
21 | .............................................................
| ||||||
22 | (insert a future date or event, such as court determination of | ||||||
23 | your
disability, if when you want this power to terminate prior | ||||||
24 | to your death)
| ||||||
25 | ( YOU CANNOT HAVE CO-AGENTS. IF YOU WISH TO NAME SUCCESSOR | ||||||
26 | AGENTS, INSERT THE NAMES AND ADDRESSES OF
SUCH SUCCESSORS IN |
| |||||||
| |||||||
1 | THE FOLLOWING PARAGRAPH.)
| ||||||
2 | 5. If any agent named by me shall die, become incompetent, | ||||||
3 | resign,
refuse to accept the office of agent or be unavailable, | ||||||
4 | I name
the following (each to act alone
and successively, in | ||||||
5 | the order named) as successors to such agent:
| ||||||
6 | .............................................................
| ||||||
7 | .............................................................
| ||||||
8 | For purposes of this paragraph 5, a person shall be considered | ||||||
9 | to be
incompetent if and while the person is a minor or an | ||||||
10 | adjudicated
incompetent or disabled person or the person is | ||||||
11 | unable to give prompt and
intelligent consideration to health | ||||||
12 | care matters, as certified by a licensed physician.
(IF YOU | ||||||
13 | WISH TO NAME YOUR AGENT AS GUARDIAN OF YOUR PERSON,
IN THE | ||||||
14 | EVENT A COURT DECIDES
THAT ONE SHOULD BE APPOINTED, YOU MAY, | ||||||
15 | BUT ARE NOT REQUIRED TO, DO SO BY
RETAINING THE FOLLOWING
| ||||||
16 | PARAGRAPH. THE COURT
WILL APPOINT YOUR AGENT IF THE COURT FINDS | ||||||
17 | THAT SUCH
APPOINTMENT WILL SERVE YOUR BEST INTERESTS AND | ||||||
18 | WELFARE. STRIKE OUT
PARAGRAPH 6 IF YOU DO NOT WANT YOUR AGENT | ||||||
19 | TO ACT AS GUARDIAN.)
| ||||||
20 | 6. If a guardian of my person is to be appointed, I | ||||||
21 | nominate the agent
acting under this power of attorney as such
| ||||||
22 | guardian, to serve without bond or security.
| ||||||
23 | 7. I am fully informed as to all the contents of this form | ||||||
24 | and
understand the full import of this grant of powers to my | ||||||
25 | agent.
|
| ||||||||||||||||||||||||||||||||||
| ||||||||||||||||||||||||||||||||||
1 | Date | |||||||||||||||||||||||||||||||||
2 | Signed..............................
| |||||||||||||||||||||||||||||||||
3 | ( principal's signature or mark principal )
| |||||||||||||||||||||||||||||||||
4 | The principal has had an opportunity to review read the | |||||||||||||||||||||||||||||||||
5 | above form and has
signed the form or acknowledged his or her | |||||||||||||||||||||||||||||||||
6 | signature or mark on the form in my presence. The undersigned | |||||||||||||||||||||||||||||||||
7 | witness certifies that the witness is not: (a) the attending | |||||||||||||||||||||||||||||||||
8 | physician or mental health service provider or relative of the | |||||||||||||||||||||||||||||||||
9 | physician or provider; (b) an owner, operator, or relative of | |||||||||||||||||||||||||||||||||
10 | an owner or operator of a health care facility in which the | |||||||||||||||||||||||||||||||||
11 | principal is a patient or resident; (c) a parent, sibling, | |||||||||||||||||||||||||||||||||
12 | descendant, or any spouse of such parent, sibling, or | |||||||||||||||||||||||||||||||||
13 | descendant of either the principal or any agent or successor | |||||||||||||||||||||||||||||||||
14 | agent under the foregoing power of attorney, whether such | |||||||||||||||||||||||||||||||||
15 | relationship is by blood, marriage, or adoption; or (d) an | |||||||||||||||||||||||||||||||||
16 | agent or successor agent under the foregoing power of attorney.
| |||||||||||||||||||||||||||||||||
| ||||||||||||||||||||||||||||||||||
25 | .......................... Residing at......................
| |||||||||||||||||||||||||||||||||
26 | (witness)
|
| |||||||
| |||||||
1 | (YOU MAY, BUT ARE NOT REQUIRED TO, REQUEST YOUR AGENT AND | ||||||
2 | SUCCESSOR AGENTS
TO PROVIDE SPECIMEN SIGNATURES BELOW. IF YOU | ||||||
3 | INCLUDE SPECIMEN SIGNATURES
IN THIS POWER OF ATTORNEY, YOU MUST | ||||||
4 | COMPLETE THE CERTIFICATION OPPOSITE THE
SIGNATURES OF THE | ||||||
5 | AGENTS.)
| ||||||
6 | Specimen signatures of I certify that the signatures of my
| ||||||
7 | agent (and successors). agent (and successors) are correct.
| ||||||
8 | ....................... ...................................
| ||||||
9 | (agent) (principal)
| ||||||
10 | ....................... ...................................
| ||||||
11 | (successor agent) (principal)
| ||||||
12 | ....................... ...................................
| ||||||
13 | (successor agent) (principal)"
| ||||||
14 | (b) The statutory short form power of attorney for health | ||||||
15 | care (the
"statutory health care power") authorizes the agent | ||||||
16 | to make any and all
health care decisions on behalf of the | ||||||
17 | principal which the principal could
make if present and under | ||||||
18 | no disability, subject to any limitations on the
granted powers | ||||||
19 | that appear on the face of the form, to be exercised in such
| ||||||
20 | manner as the agent deems consistent with the intent and | ||||||
21 | desires of the
principal. The agent will be under no duty to | ||||||
22 | exercise granted powers or
to assume control of or | ||||||
23 | responsibility for the principal's health care;
but when | ||||||
24 | granted powers are exercised, the agent will be required to use
| ||||||
25 | due care to act for the benefit of the principal in accordance | ||||||
26 | with the
terms of the statutory health care power and will be |
| |||||||
| |||||||
1 | liable
for negligent exercise. The agent may act in person or | ||||||
2 | through others
reasonably employed by the agent for that | ||||||
3 | purpose
but may not delegate authority to make health care | ||||||
4 | decisions. The agent
may sign and deliver all instruments, | ||||||
5 | negotiate and enter into all
agreements and do all other acts | ||||||
6 | reasonably necessary to implement the
exercise of the powers | ||||||
7 | granted to the agent. Without limiting the
generality of the | ||||||
8 | foregoing, the statutory health care power shall include
the | ||||||
9 | following powers, subject to any limitations appearing on the | ||||||
10 | face of the form:
| ||||||
11 | (1) The agent is authorized to give consent to and | ||||||
12 | authorize or refuse,
or to withhold or withdraw consent to, | ||||||
13 | any and all types of medical care,
treatment or procedures | ||||||
14 | relating to the physical or mental health of the
principal, | ||||||
15 | including any medication program, surgical procedures,
| ||||||
16 | life-sustaining treatment or provision of food and fluids | ||||||
17 | for the principal.
| ||||||
18 | (2) The agent is authorized to admit the principal to | ||||||
19 | or discharge the
principal from any and all types of | ||||||
20 | hospitals, institutions, homes,
residential or nursing | ||||||
21 | facilities, treatment centers and other health care
| ||||||
22 | institutions providing personal care or treatment for any | ||||||
23 | type of physical
or mental condition. The agent shall have | ||||||
24 | the same right to visit the
principal in the hospital or | ||||||
25 | other institution as is granted to a spouse or
adult child | ||||||
26 | of the principal, any rule of the institution to the |
| |||||||
| |||||||
1 | contrary
notwithstanding.
| ||||||
2 | (3) The agent is authorized to contract for any and all | ||||||
3 | types of health
care services and facilities in the name of | ||||||
4 | and on behalf of the principal
and to bind the principal to | ||||||
5 | pay for all such services and facilities,
and to have and | ||||||
6 | exercise those powers over the principal's property as are
| ||||||
7 | authorized under the statutory property power, to the | ||||||
8 | extent the agent
deems necessary to pay health care costs; | ||||||
9 | and
the agent shall not be personally liable for any | ||||||
10 | services or care contracted
for on behalf of the principal.
| ||||||
11 | (4) At the principal's expense and subject to | ||||||
12 | reasonable rules of the
health care provider to prevent | ||||||
13 | disruption of the principal's health care,
the agent shall | ||||||
14 | have the same right the principal has to examine and copy
| ||||||
15 | and consent to disclosure of all the principal's medical | ||||||
16 | records that the agent deems
relevant to the exercise of | ||||||
17 | the agent's powers, whether the records
relate to mental | ||||||
18 | health or any other medical condition and whether they are | ||||||
19 | in
the possession of or maintained by any physician, | ||||||
20 | psychiatrist,
psychologist, therapist, hospital, nursing | ||||||
21 | home or other health care
provider.
| ||||||
22 | (5) The agent is authorized: to direct that an autopsy | ||||||
23 | be made pursuant
to Section 2 of "An Act in relation to | ||||||
24 | autopsy of dead bodies", approved
August 13, 1965, | ||||||
25 | including all amendments;
to make a disposition of any
part | ||||||
26 | or all of the principal's body pursuant to the Illinois |
| |||||||
| |||||||
1 | Anatomical Gift
Act, as now or hereafter amended; and to | ||||||
2 | direct the disposition of the
principal's remains.
| ||||||
3 | (THE NAME, ADDRESS, AND PHONE NUMBER OF THE PERSON | ||||||
4 | PREPARING THIS FORM OR WHO ASSISTED THE PRINCIPAL IN COMPLETING | ||||||
5 | THIS FORM MAY OPTIONALLY BE INSERTED BELOW). | ||||||
6 | ......................... | ||||||
7 | (name) | ||||||
8 | ......................... | ||||||
9 | (address) | ||||||
10 | ......................... | ||||||
11 | (phone) | ||||||
12 | (Source: P.A. 93-794, eff. 7-22-04.)
| ||||||
13 | (755 ILCS 45/4-12) (from Ch. 110 1/2, par. 804-12)
| ||||||
14 | Sec. 4-12. Saving clause. This Act does not in any way
| ||||||
15 | invalidate any health care agency executed or any act of any
| ||||||
16 | agent done, or affect any claim, right or
remedy that accrued, | ||||||
17 | prior to September 22, 1987.
| ||||||
18 | This amendatory Act of the 96th General Assembly does not | ||||||
19 | in any way invalidate any health care agency executed or any | ||||||
20 | act of any agent done, or affect any claim, right, or remedy | ||||||
21 | that accrued, prior to the effective date of this amendatory | ||||||
22 | Act of the 96th General Assembly. |
| |||||||
| |||||||
1 | (Source: P.A. 86-736.)
|