Living Will Template

Information you will need

• Date Completed (Current Date)
• Principal Street Address
• Principal City
• Principal County
• Principal State
• Principal Last 4 SSN
• Initial: Chronic Coma / Vegetative State
• Check: Chronic Coma / Vegetative State
• Initial: Can't Communicate
• Check: Can't Communicate
• Initial: Can't Recognize Family/Friends
• Check: Can't Recognize Family/Friends
• Initial: Total Dependence on Others
• Check: Total Dependence on Others
• Initial: Other
• Check: Other
• Other Unnacceptable Quality of Life
• Choose one: Receive Food & Water
• Select one: Receive Food & Water
• Principal Name
• Witness (1) Printed Name
• Witness (1) Address
• Witness (1) Phone Number
• Witness (2) Printed Name

…and 22 more fields in the PDF.

Completed by the principal.

The form includes 1 signature line, a notary acknowledgment, a witness section.