STATUTORY DURABLE POWER OF ATTORNEY
Under Texas Probate Code §490
THE STATE OF TEXAS §
COUNTY OF TARRANT §
NOTICE: THE POWERS GRANTED BY THIS DOCUMENT ARE BROAD AND SWEEPING. THEY ARE EXPLAINED IN THE DURABLE POWER OF ATTORNEY ACT, CHAPTER XII, TEXAS PROBATE CODE. IF YOU HAVE ANY QUESTIONS ABOUT THESE POWERS, OBTAIN COMPETENT LEGAL ADVICE. THIS DOCUMENT DOES NOT AUTHORIZE ANYONE TO MAKE MEDICAL AND OTHER HEALTH-CARE DECISIONS FOR YOU. YOU MAY REVOKE THIS POWER OF ATTORNEY IF YOU LATER WISH TO DO SO.
Name of Principal:
Moore Money, also known as Morris Edward Money, Mo Money and M.E. Money
Address, Phone Number and Social Security Number of Principal:
2525 Mars Hotel
999 West L.A. Freeway
New Minglewood, TX 76999
(817) 999-9999
Soc. Sec. No.: 009-999-9999
Name of Agent (Attorney-In-Fact):
Lotta Money, also known as Lotta B. Goode, B. Goode, Mrs. Lotta Money and Mrs. Moore Money
Address, Phone Number and Social Security Number of Agent:
2525 Mars Hotel
999 West L.A. Freeway
New Minglewood, TX 76999
(817) 999-9999
Soc. Sec. No. 007-999-9999
I, Moore Money, appoint Lotta Money as my agent (attorney-in-fact) to act for me in any lawful way with respect to all of the following powers except for a power that I have crossed out below.
TO WITHHOLD A POWER, YOU MUST CROSS OUT EACH POWER WITHHELD.
Real property transactions;
Tangible personal property transactions;
Stock and bond transactions;
Commodity and option transactions;
Banking and other financial institution transactions;
Business operating transactions;
Insurance and annuity transactions;
Estate, trust, and other beneficiary transactions;
Claims and litigation;
Personal and family maintenance;
Benefits from social security, Medicare, Medicaid, or other governmental programs or civil or military service;
Retirement plan transactions;
Tax matters.
IF NO POWER LISTED ABOVE IS CROSSED OUT, THIS DOCUMENT WILL BE CONSTRUED AND INTERPRETED AS A GENERAL POWER OF ATTORNEY AND MY AGENT (ATTORNEY IN FACT) WILL HAVE THE POWER AND AUTHORITY TO PERFORM OR UNDERTAKE ANY ACTION I COULD PERFORM OR UNDERTAKE IF I WERE PERSONALLY PRESENT.
SPECIAL INSTRUCTIONS
Special instructions applicable to gifts (initial in front of the following sentence to have it apply):
I grant my agent (attorney in fact) the power to apply my property to make gifts, except that the amount of a gift to an individual may not exceed the amount of annual exclusions allowed from the federal gift tax for the calendar year of the gift. SEE BELOW.
ON THE FOLLOWING LINES YOU MAY GIVE SPECIAL INSTRUCTIONS LIMITING OR EXTENDING THE POWERS GRANTED TO YOUR AGENT.
Power to Certify Facts/Indemnification and Protection of Third Parties By Moore Money. Without limiting the foregoing, my agent will have the power to certify to any facts requested by a third party to evidence my agent's authority under this document, and any third party will be completely protected, held harmless and indemnified by me for any damages incurred as a result of relying on any such facts that turn out to be untrue.
Transfers to The Lotta Moore Money Family Trust. Without limiting the foregoing, my agent is expressly authorized to make transfers of property to the trustee, in trust, of The Lotta Moore Money Family Trust (as and if amended, adopted or restated), including any Subtrust established by or under The Lotta Moore Money Family Trust, without any restriction whatsoever.
Designating The Lotta Moore Money Family Trust as Beneficiary of Death Benefits. Without limiting the foregoing, my agent is also expressly authorized to execute any beneficiary designations on my behalf designating the trustee, in trust, of The Lotta Moore Money Family Trust (as and if amended), including any Subtrust established by or under The Lotta Moore Money Family Trust, as the beneficiary of any property or benefits under any contract or other arrangement with anyone.
Power of Substitution. Without limiting the foregoing, I hereby specially authorize my agent to make appointment of attorney by substitution and hereby ratify and confirm all such lawful acts that my agent or substitute may do or cause to be done by virtue of this document.
Power to Exercise Power of Appointment. Without limiting the foregoing, I hereby specially authorize my agent to exercise a power of appointment that I may have.
Power to Make Annual Exclusion Gifts. I hereby specially authorize my agent to make present interest gifts to my descendants or their spouses, but only if my agent reasonably believes that this will save estate taxes in my estate, and only if such gifts do not exceed $10,000 (or such lesser amount as is specified in IRC(1) §2503(b)) in any calendar year to any one person, and provided, further, that such gifts are fairly apportioned in a manner not showing favoritism or partiality. My agent may not make a gift to himself or herself, however.
Power to Make Tax Motivated Gifts. If I become incapacitated (whether or not so adjudicated), and the likelihood of my regaining capacity is determined by my Agent (acting in a fiduciary capacity) to be remote, and if, as a consequence of my incapacity, I am unable to make tax motivated gifts on my own, I specially authorize my agent to make tax motivated gifts to my descendants or their spouses, in any form or manner, provided that such gifts are fairly apportioned in a manner not showing favoritism or partiality, if my agent reasonably believes that such gifts will save estate or generation skipping taxes. My agent may not make a gift to himself or herself, however.
Power of Appointment is a Fiduciary Power and is Not a Power of Appointment. Notwithstanding the above or anything else in this document to the contrary, this power is to be held by the power holder in a fiduciary capacity for my benefit, and is not exercisable in favor of the power holder, his estate, his creditors, or the creditors of his estate. The preceding sentence will not prevent the power holder from paying my debts, even if the power holder is jointly liable along with me; however, such payment will not discharge the power holder to account to me and to reimburse me, in accordance with such principles of law and equity otherwise applicable. It is specially provided, however, that third parties relying on this power are under no duty whatsoever to determine the capacity in which the power is being exercised or the use to which it is being put. Notwithstanding the above or anything else in this document to the contrary, my agent will have no incident of ownership or other power over any policy of life insurance that insures the agent's life. (This provision will not, however, prohibit my agent from disposing of my Wife's one-half interest in our community property over which I have control and management (if any, and if I am married at the time) by conveying her interest to her or for her benefit.) The exercise of the power to transfer my property to The Lotta Moore Money Family Trust or to designate it as my death beneficiary is not prohibited by this paragraph because (a) it would be made at my direction and (b) I have retained the power to revoke and amend that trust.
Indemnification By Agent. My agent is authorized to indemnify and hold harmless any third party who accepts and acts under this power of agent.
Agent is Authorized to Sue Third Parties Who Refuse to Honor this Power. Further, my agent is authorized to take legal action to compel third parties to recognize the validity of this instrument, and my attorney-in-fact may sue for damages, both punitive and actual, in the case of a refusal by a third party to honor this power.
Revocation of Previous Powers. This power of attorney does not revoke any other powers of attorney.
Revocation of this Power. Unless this power of attorney is revoked by revocation filed with the County Clerk of Ripple County, Texas, the revocation will not be effective as to a third party relying on the power until the third party receives actual notice of the revocation. No person may exercise any power under this instrument if such person was, but is no longer, married to the Principal at the time of such purported exercise, or at such time as there is pending or in effect a legal or equitable action for, or decree or order of, annulment, divorce, separation, or separate maintenance, between the spouse and the Principal.
Multiple Power Holders. If more than one person simultaneously holds a Power of Attorney under this document, the Power must be exercised unanimously. If one or more joint holders of my power of attorney, if any, fails to qualify, is incapacitated, dies or otherwise ceases to act, the remaining joint holders (or sole holder as the case may be) of my power of attorney will hold the office, alone or jointly, as the case may be.
Definitions
As used in this instrument, the following terms, whether or not capitalized, will be given the following meanings, unless the context very clearly indicates otherwise.
a. The term "including" means "including but not limited to." The term "includes" means "includes but is not limited to." The term "include" means "include but are not limited to." Any "examples" given are by way of illustration and not by way of limitation, unless otherwise stated.
b. As used in this instrument, whenever the context so indicates, the masculine, feminine or neuter gender, and the singular or plural number, will include the others.
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UNLESS YOU DIRECT OTHERWISE ABOVE, THIS POWER OF ATTORNEY IS EFFECTIVE IMMEDIATELY AND WILL CONTINUE UNTIL IT IS REVOKED.
CHOOSE ONE OF THE FOLLOWING ALTERNATIVES BY CROSSING OUT THE ALTERNATIVE NOT CHOSEN:
(A) This Power of Attorney is not affected by my subsequent disability or incapacity.
(B) This Power of Attorney becomes effective upon my disability or incapacity.
YOU SHOULD CHOOSE ALTERNATIVE (A) IF THIS POWER OF ATTORNEY IS TO BECOME EFFECTIVE ON THE DATE IT IS EXECUTED.
IF NEITHER (A) NOR (B) IS CROSSED OUT, IT WILL BE ASSUMED THAT YOU CHOSE ALTERNATIVE (A).
If Alternative (B) is chosen and a definition of my disability or incapacity is not contained in this power of attorney, I will be considered disabled or incapacitated for purposes of this power of attorney if a physician certifies in writing at a date later than the date this power of attorney is executed that, based on the physician's medical examination of me, I am mentally incapable of managing my financial affairs. I authorize the physician who examines me for this purpose to disclose my physical or mental condition to another person for purposes of this power of attorney. A third party who accepts this power of attorney is fully protected from any action taken under this power of attorney that is based on the determination made by a physician of my disability or incapacity.
I agree that any third party who receives a copy of this document may act under it. Revocation of the Durable Power of Attorney is not effective as to a third party until the third party receives actual notice of the revocation. I agree to indemnify the third party for any claims that arise against the third party because of reliance on this Power of Attorney.
If any agent named by me dies, becomes legally disabled, resigns, or refuses to act, I name the following (each to act alone and successively, in the order named) as successor(s) to that agent:
A. First Alternate Agent
Name:
Faith N. Money (Faith)
Address, Soc. Sec. No. & Phone (if available):
221B New Minglewood Avenue
Cucamonga, CA 90210
(900) 123-4567
B. Second Alternate Agent
Name:
Infidelity Trust
Address, Soc. Sec. No. & Phone (if available):
999 Sugar Magnolia Ave.
Gray Folded, CA 90111
(555) 551-5515
Date Signed:
Sunday, November 8, 1998
Moore Money, Principal
SIGNED AND ACKNOWLEDGED IN THE PRESENCE OF:
We, the undersigned persons, of lawful age, declare that this instrument was signed and acknowledged by Moore Money, the above-named Principal, as his Power of Attorney, in our presence, and we, at his request, and in his presence, and in the presence of each other, have subscribed our names to this instrument as attesting witnesses on the day and year last above written; and we certify that, in our opinion and belief, Moore Money is of sound mind.
Cynthia L. Lee, Witness
Loma Stooksberry, Witness
THE ATTORNEY IN FACT OR AGENT, BY ACCEPTING OR ACTING UNDER THE APPOINTMENT, ASSUMES THE FIDUCIARY AND OTHER LEGAL RESPONSIBILITIES OF AN AGENT.
§STATE OF TEXAS
§COUNTY OF TARRANT
On Sunday, November 8, 1998, the above and foregoing instrument was SUBSCRIBED, SWORN TO AND ACKNOWLEDGED BEFORE ME, a Notary Public in and for the State of Texas, by Moore Money, known to me to reside in Ripple County, Texas, and by the two witnesses whose names appear above, all three of whom are personally known to me to be over eighteen years of age, and, being by me first duly sworn, each of such persons declared that the statements therein contained are true and correct and that the foregoing instrument was signed for the purposes and consideration therein expressed.
Affix Imprint of Notary Stamp Showing Name of Notary and Commission Expiration Date Immediately Under Signature
Signature of Notary
Receipt Acknowledged and Office Accepted
Date Signed:
Lotta Money, Attorney-in-Fact
DECLARATION OF GUARDIAN IN THE EVENT OF LATER INCOMPETENCE OR NEED OF GUARDIAN
In accordance with Tex. Prob. Code §679, I, Moore Money, make this Declaration of Guardian, to operate if the need for a guardian for me later arises.
1. I designate Lotta Money to serve as guardian of my person.
I designate Faith N. Money (Faith) to serve as first alternate guardian of my person.
2. I designate Lotta Money to serve as guardian of my estate.
I designate Infidelity Trust to serve as first alternate guardian of my estate.
I designate Faith N. Money (Faith) to serve as second alternate guardian of my estate.
3. If any guardian or alternate guardian dies, does not qualify, or resigns, the next named alternate guardian becomes my guardian.
4. I expressly disqualify the following persons from serving as guardian of my person: my son, Cosmic Charlie.
5. I expressly disqualify the following persons from serving as guardian of my estate: my son, Cosmic Charlie.
Date Signed:
Sunday, November 8, 1998
Moore Money
Date Signed:
Sunday, November 8, 1998
Cynthia L. Lee, First Witness
Date Signed:
Sunday, November 8, 1998
Loma Stooksberry, Second Witness
SELF-PROVING AFFIDAVIT
Before me, the undersigned authority, on this date personally appeared the declarant, Moore Money, and Cynthia L. Lee and Loma Stooksberry as witnesses, and all being duly sworn, the declarant said that the above instrument was his Declaration of Guardian and that the declarant had made and executed it for the purposes expressed in the declaration. The witnesses declared to me that they are each 14 years of age or older, that they saw the declarant sign the declaration, that they signed the declaration as witnesses, and that the declarant appeared to them to be of sound mind.
Moore Money, Affiant (Declarant)
Cynthia L. Lee, Affiant (Witness)
Loma Stooksberry, Affiant (Witness)
Subscribed and sworn to before me by the above named declarant and affiants on this Sunday, November 8, 1998 .
Affix Imprint of Notary Stamp Showing Name of Notary and Commission Expiration Date Immediately Under Signature
Signature of Notary
AFTER RECORDING RETURN TO:
Noel C. Ice
Cantey & Hanger, L.L.P.
2100 Burnett Plaza
801 Cherry Street
Fort Worth, Texas 76102-6898
PREPARED IN THE LAW OFFICE OF:
Cantey & Hanger, L.L.P. (Noel C. Ice)
2100 Burnett Plaza
801 Cherry Street
Fort Worth, Texas 76102-6898
Front Desk (817) 877-2800
Metro (817) 429-3815
Direct Line (817) 877-2885
FAX (817) 877-2807
INFORMATION CONCERNING THE DURABLE
POWER OF ATTORNEY FOR HEALTH CARE
THIS IS AN IMPORTANT LEGAL DOCUMENT. BEFORE SIGNING THIS DOCUMENT, YOU SHOULD KNOW THESE IMPORTANT FACTS:
Except to the extent you state otherwise, this document gives the person you name as your agent the authority to make any and all health care decisions for you in accordance with your wishes, including your religious and moral beliefs, when you are no longer capable of making them yourself. Because "health care" means any treatment, service, or procedure to maintain, diagnose, or treat your physical or mental condition, your agent has the power to make a broad range of health care decisions for you. Your agent may consent, refuse to consent, or withdraw consent to medical treatment and may make decisions about withdrawing or withholding life-sustaining treatment. Your agent may not consent to voluntary inpatient mental health services, convulsive treatment, psychosurgery, or abortion.
A physician must comply with your agent's instructions or allow you to be transferred to another physician.
Your agent's authority begins when your doctor certifies that you lack the capacity to make health care decisions. Your agent is obligated to follow your instructions when making decisions on your behalf. Unless you state otherwise, your agent has the same authority to make decisions about your health care as you would have had.
It is important that you discuss this document with your physician or other health care provider before you sign it to make sure that you understand the nature and range of decisions that may be made on your behalf. If you do not have a physician, you should talk with someone else who is knowledgeable about these issues and can answer your questions. You do not need a lawyer's assistance to complete this document, but if there is anything in this document that you do not understand, you should ask a lawyer to explain it to you.
The person you appoint as agent should be someone you know and trust. The person must be 18 years of age or older or a person under 18 years of age who has had the disabilities of minority removed. If you appoint your health or residential care provider (e.g., your physician or an employee of a home health agency, hospital, nursing home, or residential care home, other than a relative), that person has to choose between acting as your agent or as your health or residential care provider; the law does not permit a person to do both at the same time. You should inform the person you appoint that you want the person to be your health care agent. You should discuss this document with your agent and your physician and give each a signed copy. You should indicate on the document itself the people and institutions who have signed copies. Your agent is not liable for health care decisions made in good faith on your behalf.
Even after you have signed this document, you have the right to make health care decisions for yourself as long as you are able to do so and treatment cannot be given to you or stopped over your objection. You have the right to revoke the authority granted to your agent by informing your agent or your health or residential care provider orally or in writing or by your execution of a subsequent durable power of attorney for health care. Unless you state otherwise, your appointment of a spouse dissolves on divorce.
This document may not be changed or modified. If you want to make changes in the document, you must make an entirely new one.
You may wish to designate an alternate agent in the event that your agent is unwilling, unable, or ineligible to act as your agent. Any alternate agent you designate has the same authority to make health care decisions for you.
THIS POWER OF ATTORNEY IS NOT VALID UNLESS IT IS SIGNED IN THE PRESENCE OF TWO OR MORE QUALIFIED WITNESSES. THE FOLLOWING PERSONS MAY NOT ACT AS WITNESSES:
(1) the person you have designated as your agent;
(2) your health or residential care provider or an employee of your health or residential care provider;
(3) your spouse;
(4) your lawful heirs or beneficiaries named in your will or a deed; or
(5) creditors or persons who have a claim against you.
I acknowledge receipt of this disclosure statement prior to execution of the Durable Power of Attorney for Health Care, and I affirm that I have read and understand the information contained in this disclosure statement.
Moore Money
DURABLE POWER OF ATTORNEY FOR HEALTH CARE
DESIGNATION OF HEALTH CARE AGENT(2)
I, Moore Money appoint:
Name:
Lotta Money
Address, Soc. Sec. No. & Phone (if available):
2525 Mars Hotel
999 West L.A. Freeway
New Minglewood, TX 76999
(817) 999-9999
Soc. Sec. No. 007-999-9999
as my agent to make any and all health care decisions for me, except to the extent I state otherwise in this document. This durable power of attorney for health care takes effect if I become unable to make my own health care decisions and this fact is certified in writing by my physician.
LIMITATIONS ON THE DECISION-MAKING AUTHORITY OF MY AGENT ARE AS FOLLOWS: My Agent will honor and be bound by any Directive To Physicians that I have made under The Texas Natural Death Act,(3) if, but only if, that Directive would otherwise require (under the circumstances then existing) that life-sustaining procedures be withheld or withdrawn. The fact that I may have executed a Directive to Physicians will not limit the power of my Agent to act under this Durable Power For Health Care, unless the Directive to Physicians would otherwise operate to require that life-sustaining procedures be withheld or withdrawn.
DESIGNATION OF ALTERNATE AGENT. (You are not required to designate an alternate agent but you may do so. An alternate agent may make the same health care decisions as the designated agent if the designated agent is unable or unwilling to act as your agent. If the agent designated is your spouse, the designation is automatically revoked by law if your marriage is dissolved.)
If the person designated as my agent is unable or unwilling to make health care decisions for me, I designate the following persons to serve as my agent to make health care decisions for me as authorized by this document, who serve in the following order:
A. First Alternate Agent
Name:
Faith N. Money (Faith)
Address, Soc. Sec. No. & Phone (if available):
221B New Minglewood Avenue
Cucamonga, CA 90210
(900) 123-4567
The original of this document is kept at
Name:
Address, Soc. Sec. No. & Phone (if available):
xxxxxxsssdfwereeeexxxxxxxxxxxxxxx
The following individuals or institutions have signed copies:
Moore Money and Lotta Money
2525 Mars Hotel
999 West L.A. Freeway
New Minglewood, TX 76999
Lotta Money
2525 Mars Hotel
999 West L.A. Freeway
New Minglewood, TX 76999
(817) 999-9999
Soc. Sec. No. 007-999-9999
Noel C. Ice
Offices of Cantey & Hanger, L.L.P., 2100 Burnett Plaza, 801 Cherry Street, Fort Worth, Texas 76102-6898, (817) 877-2800, (817) 877-2885 (Direct Line).
xxxxxxsssdfwereeeexxxxxxxxxxxxxxxDURATION. I understand that this power of attorney exists indefinitely from the date I execute this document unless I establish a shorter time or revoke the power of attorney. If I am unable to make health care decisions for myself when this power of attorney expires, the authority I have granted my agent continues to exist until the time I become able to make health care decisions for myself.
(IF APPLICABLE) This power of attorney ends on the following date: Not Applicable.
PRIOR DESIGNATIONS REVOKED. I revoke any prior durable power of attorney for health care.
ACKNOWLEDGMENT OF DISCLOSURE STATEMENT. I have been provided with a disclosure statement explaining the effect of this document. I have read and understand that information contained in the disclosure statement.
I sign my name to this durable power of attorney for health care on
Sunday, November 8, 1998 at Fort Worth, Tarrant County, Texas.
Moore Money, Principal
STATEMENT OF WITNESSES.
I declare under penalty of perjury that the principal has identified himself or herself to me, that the principal signed or acknowledged this durable power of attorney in my presence, that I believe the principal to be of sound mind, that the principal has affirmed that the principal is aware of the nature of the document and is signing it voluntarily and free from duress, that the principal requested that I serve as witness to the principal's execution of this document, that I am not the person appointed as agent by this document, and that I am not a provider of health or residential care, an employee of a provider of health or residential care, the operator of a community care facility, or an employee of an operator of a health care facility.
I declare that I am not related to the principal by blood, marriage, or adoption and that to the best of my knowledge I am not entitled to any part of the estate of the principal on the death of the principal under a will or by operation of law.
Witness Signature:
Print Name:
Cynthia L. Lee
Date Signed:
Sunday, November 8, 1998
Address:
2100 Burnett Plaza, 801 Cherry Street, Fort Worth, Texas 76102.
Witness Signature:
Print Name:
Loma Stooksberry
Date Signed:
Sunday, November 8, 1998
Address:
2100 Burnett Plaza, 801 Cherry Street, Fort Worth, Texas 76102.
§STATE OF TEXAS
§COUNTY OF TARRANT
On the date last above written, the above and foregoing instrument was SUBSCRIBED, SWORN TO AND ACKNOWLEDGED BEFORE ME, a Notary Public in and for the state of Texas, by Moore Money and the two witnesses whose names last appear above, each of whom personally appeared before me, and who are personally known to me (or proved to me on the basis of satisfactory evidence) to be the persons whose names are subscribed to the foregoing instrument and, being by me first duly sworn, declared that the statements th
erein contained are true and correct and that the foregoing instrument was signed for the purposes and consideration therein expressed.
GIVEN UNDER MY HAND AND OFFICIAL SEAL OF OFFICE on the day and the year last above written.
Affix Imprint of Notary Stamp Showing Name of Notary and Commission Expiration Date Immediately Under Signature
Signature of Notary
DIRECTIVE TO PHYSICIANS
Made Under The Texas Natural Death Act(4)
Directive made and signed on the date of my signature as set forth below.
I, Moore Money, being of sound mind, willfully and voluntarily make known my desire that my life will not be artificially prolonged under the circumstances set forth in this directive.
1. If at any time I should have an incurable or irreversible condition caused by injury, disease, or illness certified to be a terminal condition by two physicians, and if the application of life-sustaining procedures would serve only to artificially postpone the moment of my death, and if my attending physician determines that my death is imminent or will result within a relatively short time without the application of life-sustaining procedures, I direct that those procedures be withheld or withdrawn, and that I be permitted to die naturally.
2. In the absence of my ability to give directions regarding the use of those life-sustaining procedures, it is my intention that this directive be honored by my family and physicians as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences from that refusal.
3. RESERVED.
4. This directive is in effect until it is revoked.
5. I understand the full import of this directive and I am emotionally and mentally competent to make this directive.
6. I understand that I may revoke this directive at any time.
Date Signed:
Sunday, November 8, 1998
Moore Money
City, County, and State of Residence: New Minglewood, Ripple County, Texas.
Two witnesses must sign the directive in the spaces provided below.
I am not a person designated by Moore Money ("the declarant") to make a treatment decision. I am not related to the declarant by blood or marriage. I would not be entitled to any portion of the declarant's estate on the declarant's death. I am not the attending physician of the declarant or an employee of the attending physician. I have no claim against any portion of the declarant's estate on the declarant's death. Furthermore, if I am an employee of a health care facility in which the declarant is a patient, I am not involved in providing direct patient care to the declarant and am not an officer, director, partner, or business office employee of the health care facility or of any parent organization of the health care facility.
Date Signed:
Sunday, November 8, 1998
Cynthia L. Lee, First Witness
Date Signed:
Sunday, November 8, 1998
Loma Stooksberry, Second Witness
UNIFORM ANATOMICAL GIFT ACT
DONOR FORM
Donor's full name: Moore Money
Street address: 2525 West L.A. Freeway, New Minglewood, TX 76999, (817) 999-9999
Social Security Number: 009-999-9999
Date of Birth: 10/1/29
Place of Birth: Desert City, Lion's Den County, Texas
Donor's next of kin: Lotta Money
Relationship to donor: Wife
Street address of next of kin: 2525 West L.A. Freeway, New Minglewood, TX 76999, (817) 999-9999
In hope that I may help others, I hereby make this anatomical gift, if medically acceptable, to take effect upon my death. The words and marks below indicate my desires:
I give to the Living Bank any needed organs and tissues.
In the event that the Living Bank is unable to accept this gift by reason of the time or place of my death, or for any other reason declines to accept this gift, then I direct that this gift may be received by any institution of similar purpose that is authorized by law to accept this gift. One such institution would be Midwest Organ Bank, 1900 W. 47th Place, Ste. 400, Westwood, KS 66205, (913) 262-1666.
Signed by the donor and two witnesses of legal age, in the presence of each other.
Date Signed:
Sunday, November 8, 1998
Moore Money, Donor
Date Signed:
Sunday, November 8, 1998
Lotta Money (Wife of Donor), First Witness
Date Signed:
Sunday, November 8, 1998
Cynthia L. Lee, Second Witness
Instructions When this form is completed and returned to The Living Bank, a donor card will be sent to you, to be carried with your driver's license at all times. The form and card are legal documents in all 50 states.
The Living Bank
P. O. Box 6725
Houston, Texas 77265
(800) 528-2971
(713) 528-2971
The form must be signed by yourself and two witnesses of legal age. At least one witness must be a parent or legal guardian if the donor is a minor. The donor and witnesses must sign the form in one another's presence. Your next of kin is preferred as a witness, assuring that he or she knows of your decision.
Funeral and Burial Instructions
Moore Money
Choose those provisions from the list below that describe your desires by initialing the applicable blanks in the left hand column and by filling in any other needed information in the blanks provided in the right hand column.
Initials
FUNERAL
according to the ritual of [identify religious or other organization].
[OR]
as follows
[Specify.]
[OR]
I direct that my funeral and burial be conducted in accordance with the instructions previously given by me in that certain agreement dated
entered into between myself and
[name and address of funeral home.]
Initials
INTERNMENT/CREMATION
I further direct that my remains be
[Specify. E.g., buried in the family plot at (name and address of cemetery) ]
[OR]
I direct that my body be cremated, and that the ashes be placed in
[describe container or other receptacle for ashes] and thereafter be
[Specify. E.g., retained at the
(name of mausoleum or memorial park) at
(address) or other disposition. E.g., scattered over the Gulf of Mexico.]
Initials
PURCHASE OF HEADSTONE/MONUMENT
I direct my Executor to purchase, for a sum not to exceed $ ,
a [headstone or marker or monument] for my grave, on which there will be inscribed the words, "
"
[or state any other suitable description of type of headstone, marker, or monument that you desire.] This
[headstone or marker or monument] will be placed on my grave as soon as practicable.
[AND/OR]
Agency Alternative To the Above
§711.002 of the Texas Health and Safety Code provides
§ 711.002. Disposition of Remains; Duty to Inter
(a) Unless a decedent has left directions in writing for the disposition of the decedent's remains as provided in Subsection (g), the following persons, in the priority listed, have the right to control the disposition, including cremation, of the decedent's remains, will inter the remains, and are liable for the reasonable cost of interment:
(1) the person designated in a written instrument(5) signed by the decedent;
(2) the decedent's surviving spouse;
(3) any one of the decedent's surviving adult children;
(4) either one of the decedent's surviving parents;
(5) any one of the decedent's surviving adult siblings; or
(6) any adult person in the next degree of kinship in the order named by law to inherit the estate of the decedent.
(b) The written instrument referred to in Subsection (a)(1) will be in substantially the following form: . . .
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My Executor is directed to take all actions necessary to comply with these instructions. No different funeral or burial arrangements may be made or entered into by my heirs or by my Executor.
Date Signed:
Moore Money
1. *All references herein to the "IRC" are to the Internal Revenue Code of 1986, as amended, unless otherwise indicated.
2. 1Tex. Rev. Civ. Stat. art. 4590h-1.
3. 1Health and Safety Code Chapter 672.
4. 2Texas Health and Safety Code, Chapter 672.
5. 3Special Notes From Counsel: The provisions of this instrument, if completed, serve as the written direction described in the statute quoted in the box above. If (1) you did not complete any of the foregoing provisions of this instrument, or did not sign it, and (2) would prefer to give a disposition power to someone who would not otherwise have that power under the statute, then we will prepare the statutory form for you, if you request it.
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