1I, ______________________________ revoke any previous power of attorney for personal care made by me and APPOINT: ___________________________________________________________________________ to be my attorney(s) for personal care in accordance with the Substitute Decisions Act, 1992.

[Note: A person who provides health care , residential, social, training, or support services to the person giving this power of        attorney for compensation may not act as his or her attorney unless that [person is also his or her spouse, partner, or relative.]

 11. If you have named more than one attorney and you want them to have the authority to act separately, insert the words “jointly and severally” here: _________________________

 111. If the person(s) I have appointed, or any one of them, cannot or will not be my attorney because of refusal, resignation, death, mental incapacity, or removal by the Court, I SUBSTITUTE: ________________________________________ to act as my attorney for personal care in the same manner and subject to the same authority as the person he or she is replacing.

 1V. I give my attorney(s) the AUTHORITY to make any personal care decision for me that I am mentally incapable of making for myself, including the giving or refusing of consent to any matter to which the Health Care Consent Act, 1996 applies, subject to the Substitute Decisions Act, 1992, and any instructions, conditions or restrictions contained in this form.


Attach, sign, and date additional pages if required (this part may be left blank.)

 SIGNATURE: _____________________________________________DATE: __________________


[Note:  The following people cannot be witnesses: the attorney or his or her spouse or partner; the spouse, partner, or child of the person making the document, or someone that the person treats as his or her child; a person whose property is under guardianship or who has a guardian of the person; a person under the age of 18.]


Witness #1: Signature: _______________________________

Print Name: _________________________

Address: _____________________________________________________________________________


Witness #2: Signature: ______________________________

Print Name: _________________________

Address: _____________________________________________________________________________





 It is recommended that wills and powers of attorneys are drafted through a lawyer especially in more complex situations.   The above content should only be used in very basic situations and should be witnessed by persons that are unrelated and not named as beneficiaries, executors, or powers of attorneys.

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