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� , 2 0120556v WARNING TO PERSON EXECUTING A POWER OF ATTORNEY FOR HEALTH CARE This is an important legal document. It creates a power of attorney for health care. Before signing this document you should know these important facts: (a) This document gives the person you designate as your attorney in fact the power to make health care decisions for you when you are determined to be incapable. Although not necessary and neither encouraged nor discouraged, you may wish to state instructions or wishes and limit the authority of your attorney in fact; (b) Subject to the limitation stated in subdivision (d) of this document, the person you designate as your attorney in fact has a duty to act consistently with your desires as stated in this document or otherwise made known by you or, if your desires are unknown, to act in a manner consistent with your best interests. The person you designate in this document does, however, have the right to withdraw from this duty at any time; (c) You may specify that any determination that you are incapable of making health care decisions must be confirmed by a second physician; (d) The person you designate as your attorney in fact will not have the authority to consent to the withholding or withdrawal of life-sustaining procedures or of artificially administered nutrition or hydration unless you give him or her that authority in this power of attorney for health care or in some other clear and convincing manner; (e) This power of attorney for health care should be reviewed periodically. It will continue in effect indefinitely unless you exercise your right to revoke it. You have the right to revoke this power of attorney at any time while you are competent by notifying the attorney in fact or your health care provider of the revocation orally or in writing; (� Despite any provisions in this power of attorney for health care, you have the right to make health care decisions for yourself as long as you are not incapable of making those decisions; and (g) If there is anything in this power of attorney for health care you do not understand, you should seek legal advice. This power of attorney for health care will not be valid for making health care decisions unless it is signed by two qualified witnesses who are personally known to you and who are present when you sign or acknowledge your signature. The undersigned hereby acknowledges that the undersigned has read and understands the above and foregoing Warning. � �/� � ��'.//�.s/��i'�' •�- ' �- •