Louisiana Living Will

Information you will need

• Principal Signing Month
• Principal Name
• Life Sustaining Procedures
• City Parish, State of Residence
• Part 1 Execution Date
• Witness Name
• Witness Address
• Witness City
• Witness State and ZIP Code
• Part 2 Execution Date
• Living Will Execution
• Health Care POA Execution
• Agent Name
• Agent Address
• Agent Daytime Area Code
• Agent Daytime Phone Number
• Agent Evening Area Code
• Agent Evening Phone Number
• Advance Directive Execution Date
• Principal Signing Day
• Principal Signing Year

Completed by the agent and the provider.

The form includes 1 signature line, a witness section.