Thepurposeofthispowerofattorneyistogivethepersonyoudesignate(Your Agent

DURABLEPOWEROFATTORNEY

NOTICE

THEPURPOSEOFTHISPOWEROFATTORNEYISTOGIVETHEPERSONYOUDESIGNATE(YOUR“AGENT”)BROADPOWERS,WHICHMAYINCLUDEPOWERSTOMAKEDECISIONSRELATINGTOYOURHEALTHCARE,WITHOUTADVANCENOTICETOYOUORAPPROVALBYYOU.

THISPOWEROFATTORNEYDOESNOTIMPOSEADUTYONYOURAGENTTOEXERCISEGRANTEDPOWERS,BUTWHENPOWERSAREEXERCISED,YOURAGENTMUSTUSEDUECARETOACTFORYOURBENEFITANDINACCORDANCEWITHTHISPOWEROFATTORNEY.

YOURAGENTMAYEXERCISETHEPOWERSGIVENHERETHROUGHOUTYOURLIFETIME,INCLUDINGAFTERYOUBECOMEINCAPACITATED,UNLESSYOUEXPRESSLYLIMITTHEDURATIONOFTHESEPOWERSORYOUREVOKETHESEPOWERSORACOURTACTINGONYOURBEHALFTERMINATESYOURAGENT’SAUTHORITY.

ACOURTCANTAKEAWAYTHEPOWERSOFYOURAGENTIFITFINDSYOURAGENTISNOTACTINGPROPERLY.

THEPOWERSANDDUTIESOFANAGENTUNDERAPOWEROFATTORNEYAREEXPLAINEDMOREFULLYIN20PA.C.S.CH.56.

IFTHEREISANYTHINGABOUTTHISFORMTHATYOUDONOTUNDERSTAND,YOUSHOULDASKALAWYEROFYOUROWNCHOOSINGTOEXPLAINITTOYOU.

IHAVEREADORHADEXPLAINEDTOMETHISNOTICEANDIUNDERSTANDITS

CONTENTS.

(PRINCIPAL)(DATE)

KNOWALLMENBYTHESEPRESENTS:

That I,

of

County,Pennsylvania,do

constituteandappoint of County,Pennsylvaniatobemytrueandlawfulattorneyhavingfullpowertoactforme,andinmyname,placeandstead,but onlyintheeventIshouldbecomeincompetenttogivemyconsenttothefollowingactsorthings:

(1)Toauthorizemedicalandsurgicalprocedures.

(2) TOMAKEDECISIONSASTOWHETHERORNOTTOENROLLMEASAHUMANSUBJECTASPARTOFABIOMEDICALORBEHAVIORALRESEARCHPROJECTORSTUDY,ANDIGRANTTHISAUTHORITYUNDERTHISPOWEROFATTORNEYWITHTHEKNOWLEDGETHATTHEREMAYBENOBENEFITTOMEIFIBECOMEAPARTICIPANTINSUCHARESEARCHPROJECTORSTUDYANDTHATMYCONDITIONMAYWORSENASARESULTOFSUCHPARTICIPATION.

AndIherebyratifyandconfirmallthatmysaidattorneyshalllawfullydoorcausetobedonebyvirtueofthepowersconferredbythisDurablePowerofAttorney,includinganythingdonebetweenitsrevocationbymydeathorbywritteninstrumentexecutedbymepriortomydeath,andnoticeofsaidrevocationreachingmyattorney;provided,however,thatasagainstmeandallpersonsclaimingunderme,everythingwhichmyattorneyshalldoorcausetobedoneunderthisDurablePowerofAttorneysubsequenttosaidnoticeofrevocationreachingmysaidattorneyshallbevalidandeffectiveinfavorofanypersonclaimingthebenefitthereofwhobeforethedoingthereofshallnothavehadnoticeofsuchrevocation.

AnypersonmaydealwithmysaidattorneyinfullreliancethatthisDurablePowerofAttorneyhasnotbeenrevokeduponthesubmissionofwrittenstatementtothateffectbymysaidattorney,accompaniedbyasignedcounterparthereoforbyareproducedcopyofasignedcounterpartthereof.

INWITNESSWHEREOF,Ihavehereuntosubscribedmynameandaffixedmysealthis

dayof ,20___.

PRINCIPAL:

By: PrintName: Address:

WITNESS:

By: PrintName: Address:

Date:

I, ,HAVEREADTHEATTACHEDDURABLEPOWEROFATTORNEYANDAMTHEPERSONIDENTIFIEDASTHEAGENTFORTHEPRINCIPAL.IHEREBYACKNOWLEDGETHATINTHEABSENCEOFASPECIFICPROVISIONTOTHECONTRARYIN THISDURABLEPOWEROFATTORNEYORIN20PA.C.S.,WHENIACTASAGENT:

• ISHALLEXERCISETHEPOWERSFORTHEBENEFITOFTHEPRINCIPAL

• ISHALLEXERCISEREASONABLECAUTIONANDPRUDENCE

(AGENT)(DATE)