I, ______________________________________, of ___________________________, ___________________, in the County of ___________________________ and the State of ____________________, being of sound mind and body and being presently able to manage, without the supervision of a guardian, all aspects of my personal care and financial affairs, do hereby state, declare, and nominate as follows: If there should ever come a time when I am found by a court of competent jurisdiction to be unable to manage, without the supervision of a guardian, some or all aspects of my personal care or financial affairs, then it is my strong wish and desire that my friend, companion, and life partner, _________________________________, be appointed my guardian, notwithstanding the willingness, capability, or availability of any of my near relatives so to serve. It is my belief that ______________________________ is the person most able and likely to promote my well-being, protect me from violations of my human and civil rights, and ensure that I receive those benefits and services that I may need to develop and maximize my opportunity for self-reliance and social and financial independence. It is my belief that _________________________ has the ability to carry out all of the powers and duties of guardianship, and I trust _____________________’s integrity and judgment in all matters relating to my personal care and financial affairs. IN WITNESS WHEREOF, I have hereunto signed my name this ____ day of _________________, 20__, at ______________________, ______________.
__________________________________________ CLIENT’S NAME Witnesses ____________________________ executed this document in our presence and each of us declares that _______________________ appears to be of sound mind and free from duress at the time he/she signed this document. ______________________ affirmed that he/she is aware of the nature of the document and is signing it freely and voluntarily.
_______________________________ Residing at ______________________________ _______________________________ Residing at ______________________________
State of _______________ County of _____________
At _________________________, __________________, on the ____ day of 20__, ___________________________ personally appeared before me. He/She acknowledged this instrument, by him/her sealed and subscribed, to be his/her free act and deed.
__________________________________________ Notary Public