California Advance Health Care Directive

NOTICE TO CLIENT – MY MOBILE NOTARY PUBLIC & DOCUMENT SERVICES, LLC IS NOT A LAW FIRM, AND ITS STAFF ARE NOT ATTORNEYS. WE MAY ONLY PROVIDE SELF-HELP DOCUMENT PREPARATION SERVICES AT YOUR SPECIFIC DIRECTION. WE CANNOT PROVIDE LEGAL ADVICE, LEGAL OPINIONS, OR LEGAL REPRESENTATION. WE CANNOT ADVISE YOU REGARDING YOUR LEGAL RIGHTS,REMEDIES, DEFENSES, OPTIONS, OR STRATEGIES.

Name of Person completing this form:

First NameLast Name

Email of Person completing this form:

example@example.com

Phone Number of Person completing this form:

Please enter a valid phone number.Format: (000) 000-0000.

By submitting this information, you acknowledge and confirm that you are either the named Principal or an Authorized Representative who has obtained the Principal's permission to provide information for the preparation of these documents.

Because these documents may grant another individual significant authority over the Principal's financial, personal, or medical affairs, My Mobile Notary Public & Document Services, LLC reserves the right to communicate directly and independently with the Principal to verify their identity, confirm their wishes, and ensure the documents are being prepared voluntarily and without undue influence or coercion.

Select the documents you would like to have prepared: Please note that each document selected will incur a separate preparation fee. The total document preparation cost will be confirmed with you before document preparation begins.

The Principal's Full Legal Name

PrefixFirst NameMiddle NameLast Name

The Principal's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

The Principal's Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

The Principal's Birthday

Date

How Many Agent's will be named?

THE AGENT /ATTORNEY-IN-FACT (The primary healthcare decision maker)

PrefixFirst NameMiddle NameLast Name

The Agent's Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

The Agent's Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

The Agent's Email address:

example@example.com

ALTERNATE AGENT (The backup health care decision maker)

PrefixFirst NameMiddle NameLast Name

Alternate Agent's Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Alternate Agent's Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Alternate Agent's Email

example@example.com

Second Alternate Agent's Name

PrefixFirst NameMiddle NameLast Name

Second Alternate Agent's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Second Alternate Agent's Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Second Alternate Agent's Email

example@example.com

If Selecting More than One (1) agent, must the Agents act:

HEALTH CARE DIRECTIVE: LIFE-SUSTAINING MEASURES

If the Principal is incapacitated, has an irreversible condition, and cannot communicate, choose their instructions.

Select from the choices below to designate your wishes for medical care.

Artificial Nutrition (Feeding Tubes):

Artificial Hydration (IV Fluids):

General End-of-Life Decision:

Provide Cardiopulmonary Resuscitation (CPR):

ORGAN DONATION OPTIONS:

Quality Selection:

If you selected Limited: Type in the organs to be donated below:

Purpose Selection:

Recipient Selection:

If you selected Limited Above: Type in the Recipient that you wish to receive the doanted organs.

Do you have any special wishes to include in your California Advance Health Care Directive? IF yes, type them in below:

If you selected the Final Disposition Authorization form, enter your Funeral and Burial Instructions here: (e.g., cremation, burial plot locations, or specific service preferences)

Would you like to add on Notary Services? Total notary service fee will vary based on the number of documents to be notarized and where the document signing will take place. The Total Notary cost will be discussed with you before a notary appointment is scheduled. (If selected, this fee will be in addtion to the document preparation fee)

SIGNING VERIFICATION & IDENTIFICATION REQUIREMENTS: California Notary law requires specific verification methods for notarizing or witnessing these documents. Principal's Identification Status:

Notary Communication & Language Logistics: Documents will be prepared strictly in English. To ensure a lawful notary public signing, the Notary and the Principal must be able to communicate directly without a translator to complete the Notarization of the document. (An additional fee may be required to obtain a bilingual notary.)

If you selected NO above, enter the spoken language of the Principal below:

FORM COMPLETION & CAPACITY STATEMENT: This section must be filled out by the individual delivering this information to the LDA.

Statement of Principal Capacity (Required if completed by Representative):