HARRY HUGHES, Governor

2949

UNDERSIGNED WHO, AT _______ REQUEST, IN _____ PRESENCE, AND IN

THE PRESENCE OF EACH OTHER, HAVE HEREUNTO SIGNED OUR NAMES AND

WITNESSES WITNESSED THIS ___ DAY OF ____________ 19__, AND

DECLARE: THE DECLARANT IS PERSONALLY KNOWN TO ME, AND I BELIEVE
THE DECLARANT TO BE OF SOUND MIND. I DID NOT SIGN THE
DECLARANT'S SIGNATURE TO THIS DECLARATION. BASED UPON
INFORMATION AND BELIEF, I AM NOT RELATED TO THE DECLARANT BY
BLOOD OR MARRIAGE, A CREDITOR OF THE DECLARANT, ENTITLED TO ANY
PORTION OF THE ESTATE OF THE DECLARANT UNDER ANY EXISTING
TESTAMENTARY INSTRUMENT OF THE DECLARANT, FINANCIALLY OR
OTHERWISE RESPONSIBLE FOR THE DECLARANT'S MEDICAL CARE, OR AN
EMPLOYEE OF ANY SUCH PERSON OR INSTITUTION.

__________________________________ ADDRESS _________________________________

__________________________________ ADDRESS _________________________________

(2) THE DECLARATION MAY INCLUDE ADDITIONAL PROVISIONS
ON THIS OR OTHER SUBJECTS THAT ARE NOT INCONSISTENT WITH OTHER
PROVISIONS OF THIS SUBTITLE. IF ANY ADDITIONAL PROVISIONS ARE
DECLARED INVALID, THE INVALIDITY DOES NOT AFFECT THE VALIDITY OF
THE DECLARATION OR OF OTHER PROVISIONS WHICH CAN BE GIVEN EFFECT
WITHOUT THE INVALID PROVISION, AND TO THIS END THE PROVISIONS IN
THE DECLARATION ARE SEVERABLE.

5-603.

A DECLARANT MAY REVOKE A DECLARATION AT ANY TIME BY:

(1)  A WRITTEN STATEMENT TO THAT EFFECT:

(I)  SIGNED AND DATED BY THE DECLARANT; OR

(II)  IF THE STATEMENT SO INDICATES, SIGNED AND
DATED BY A PERSON ACTING AT THE DIRECTION OF THE DECLARANT.

(2)  A VERBAL AN EXPRESSION TO THAT EFFECT, AFTER THE
DECLARANT KNOWS OF THE DISEASE, ILLNESS, OR INJURY INVOLVED IN
ANY QUESTION REGARDING THE EXISTENCE OF A TERMINAL CONDITION, TO
THE ATTENDING PHYSICIAN AT THAT TIME;

(3)  DESTROYING THE DECLARATION;

(4)  MARKING, BURNING, TEARING, OR OTHERWISE ALTERING,
DEFACING, OR DAMAGING THE DECLARATION IN A MANNER INDICATING THE
INTENTION TO REVOKE IT.

5-604.