Kansas Advance Directive

Information you will need

• Principal Name
• Principal DOB
• Agent Name
• Agent Home Telephone Number
• Agent Work Telephone Number
• Agent Street Address
• Agent City
• Agent State/ZIP
• First Alternate Agent Name
• First Alternate Agent Home Telephone Number
• First Alternate Agent Work Telephone Number
• First Alternate Agent Street Address
• First Alternate Agent City
• First Alternate Agent State/ZIP
• Second Alternate Agent Name
• Second Alternate Agent Home Telephone Number
• Second Alternate Agent Work Telephone Number
• Second Alternate Agent Street Address
• Second Alternate Agent City
• Second Alternate Agent State/ZIP
• Organ and Tissue Donor
• Page Attached
• Notary Only: County
• Notary Only: State

…and 21 more fields in the PDF.

Completed by the agent and the declarant and the provider.

The form includes 3 signature lines, a notary acknowledgment, a witness section.