Can I eSign this Declaration?

Yes in most states under the ESIGN Act (15 U.S.C. §7001) and UETA where adopted, but check local exceptions for wills and certain court filings; confirm the receiving institution accepts electronic execution.

Are witnesses always required?

Witness requirements vary by state. Some states require two witnesses for durable POAs (for example Florida); others accept notarization alone. Verify the principal’s state law before execution.

Do banks accept an electronic POA?

Many banks accept notarized or eSigned POAs, but acceptance policies differ; provide bank-specific forms or a notarized original if requested and confirm requirements in advance.

Can I use remote online notarization?

Remote Online Notarization (RON) is permitted in most states with specific identity proofing and recordkeeping rules; verify the state’s permanent RON status and notary requirements.

How do I revoke the Declaration?

Revoke in writing, sign and date the revocation, notify agents and institutions, and record revocation where the original was recorded to ensure third‑party notice.

Which eSignature plan supports notarization or HIPAA?

Plans differ; signNow offers Business, Business Premium, Enterprise, and Site License tiers and supports HIPAA (BAA required) and advanced features on higher tiers.

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Declaration Relating to Life Sustaining and Durable Power of Attorney

Declaration Relating to Life Sustaining and Durable Power of Attorney

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

REVOCATION OF
HEALTH CARE DECLARATION

I, Declarant, having executed a Health Care Declaration regarding the use of life sustaining procedures on the day of , 20

The Arkansas Code §20-17-204 provides that a declaration may be revoked at any time and in any manner by me, without regard to my mental or physical condition.

This is my written revocation of the above referenced Declaration and I am providing a copy of this revocation to all parties to whom I provided a copy of the original declaration.

DATED this the day of , 20

Signature of Declarant:

Printed Name of Declarant:

Address of Declarant:

What this Declaration Is and when it’s used

The Declaration Relating to Life Sustaining and Durable Power of Attorney is a combined legal form that names an agent to make health care decisions regarding life-sustaining treatment and separately grants durable authority to act on financial or property matters. It records the principal’s instructions about life-sustaining interventions, identifies one or more agents for medical and financial decisions, and includes durable language that survives incapacity. The form may require witness signatures and notarization depending on state law; it can be completed on paper or electronically where ESIGN/UETA permit electronic execution.

Why a clear Declaration matters for end‑of‑life planning

A well‑drafted Declaration ensures your wishes about life‑sustaining care are documented and names an agent who can act immediately if you become incapacitated, while the durable power of attorney preserves continuity for financial affairs without court intervention.

Who typically completes this Declaration

The form is appropriate for individuals of sound mind who can appoint trusted agents and specify instructions for life sustaining treatment and financial authority.

Adults planning for incapacity who want a single record for health and finance
Caregivers coordinating medical decisions for an aging or chronically ill relative
Attorneys and advisors preparing comprehensive estate and incapacity planning documents

Primary roles involved

Principal

The individual completing the Declaration. Must be legally competent when signing, must provide full legal name and contact information, and should clearly state preferences about life‑sustaining treatment and durable powers.

Agent

The person appointed to act on behalf of the principal. Carrying out medical or financial duties requires understanding the principal’s instructions, legal authority under the document, and any state-specific witnessing or notarization conditions.

Key compliance and security notes

Encryption: TLS 1.2/1.3 in transit

Data at rest: AES-256 encryption

Audit trail: Signed event log retained

HIPAA: BAA available when required

21 CFR Part 11: Compliant options available

Standards: SOC 2 Type II and ISO 27001

Short list of legal risks if the form is defective

Invalid execution: May be unenforceable

Improper witnesses: Could void health directives

Missing durable clause: Power may terminate on incapacity

Agent overreach: Civil liability exposure

Notarization errors: Recording or acceptance denied

Outdated form: Inconsistent with current wishes

Common preparation problems to avoid

Using informal language or vague terms that leave the scope of authority unclear and invite disagreement among family members or providers.
Failing to include a durable clause so the financial Power of Attorney terminates once the principal becomes incapacitated.
Not verifying state witness and notarization requirements, causing rejection by hospitals, banks, or registries when presented.
Neglecting to provide alternate agents and contact details, which can delay decisions if the primary agent is unavailable.

Step-by-step: Completing the Declaration correctly

Follow these steps in order to prepare a clear, enforceable Declaration that covers both life‑sustaining treatment choices and durable financial authority.

01

Identify yourself: Enter full legal name exactly as on ID.
02

Name your agent: Provide full name, contact, and relationship.
03

State instructions: Be specific about life‑sustaining preferences.
04

Sign, witness, notarize: Follow state witness and notary rules carefully.

How the execution and delivery process usually runs

A typical completion workflow includes drafting, signing, authentication, and distribution to medical and financial custodians.

Prepare document: Draft with clear agent powers and medical directives.
Authenticate signer: Use ID checks, notarization, or eSignature authentication.
Execute with witnesses: Collect required witness signatures if state law requires them.
Distribute copies: Provide signed copies to agent, physicians, and bank.

Main parts of a professional Declaration

A complete Declaration combines medical directives and durable powers with clear identification and execution clauses; each section should be unambiguous to minimize disputes and acceptance problems.

Principal Details

Full legal name, date of birth, address, and any identifying numbers used for verification by institutions or notaries.

Agent Designation

Primary and alternate agent names, contact details, relationship, and any succession rules for agent replacement.

Durable Language

Explicit statement that the financial power survives incapacity, using phrasing required or recommended by state law where necessary.

Life‑Sustaining Instructions

Clear choices about resuscitation, mechanical ventilation, tube feeding, and comfort measures, with space for conditional statements.

Scope of Powers

Detailed listing of financial authorities—bank accounts, real estate, tax filings—plus any limitations or excluded powers.

Execution Block

Signature lines for the principal, witness and witness contact, notarization block, and dates that confirm when powers take effect.

Supporting items and output formats to include

Collecting supporting documentation and choosing the right file formats reduces acceptance friction with hospitals, banks, and courts.

Accepted Formats

Provide signed outputs as PDF/A or standard PDF and keep a Word DOCX source for edits; institutions commonly accept PDF.

Signed Record

A tamper‑evident signed PDF with an audit trail provides proof of execution and the signing event details.

Consent Evidence

Include any ESIGN consumer disclosure if the principal consented to electronic delivery of records for consumer-facing transactions.

Notary Acknowledgement

Attach the notary certificate and any audio‑video RON recording reference if notarized remotely.

Practical tips for accuracy and acceptance

Adopt careful editing and distribution practices to make the Declaration easy to rely on by third parties.

Use exact legal names

Enter the principal and agent names exactly as on government ID. Mismatch can cause banks or hospitals to refuse the document.

Be specific about powers

List powers clearly and avoid ambiguous phrases. Specify any limits on financial authority, such as excluding gifts or transfers to agent.

Follow state execution rules

Confirm the number of witnesses and notary requirements in the principal’s state before signing to avoid invalidation.

Distribute certified copies

Provide signed, dated copies to named agents, primary care physicians, banks, and the principal’s attorney to facilitate reliance.

Timing and important dates to record

Document dates determine effect, revocation timing, and may influence statutory notice requirements.

Effective Date:

Enter MM/DD/YYYY for when powers start.

Immediate vs Conditional:

Specify if powers are effective immediately or upon incapacity.

Recording Window:

Record with county if real estate authority is included.

Notice of Revocation:

Deliver written revocation to agents and institutions promptly.

Review Schedule:

Revisit the document periodically and when circumstances change.

Typical online workflow settings for electronic completion

Configure authentication, notarization, and routing before sending to ensure signed documents meet legal and institutional requirements.

Field	Configuration
Authentication Method	Email link, SMS code, or two‑factor
Notarization	RON enabled or in‑person notary option
Template Settings	Locked fields and required initials per page
Audit Trail	Enable IP, timestamp, and event logging

Technical and distribution considerations for eSigning

Confirm platform support for required authentication methods, RON or in‑person notarization, and output formats before execution.

File types supported: PDF, DOCX, HTML, Excel
Integrations: Salesforce, NetSuite, Microsoft 365
RON and Notary: Audio‑video recording and credentialing

Typical eSignature vendor pricing and feature snapshot

Comparison of starting prices and common feature checks for popular eSignature providers; signNow appears first per comparison rules.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day trial	Varies by vendor	Varies by vendor	Varies by vendor	Varies by vendor
Bulk Send	Yes (Business Premium)	Yes	Yes	Yes	Varies
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No
Envelope Cap	No cap	100 envelopes/user/year	Varies by plan	Varies by plan	Varies by plan

Frequently asked questions and quick answers

Answers address common legal and technical questions when preparing, signing, and using a Declaration relating to life‑sustaining care and durable powers.

Need help? Contact support

Can I eSign this Declaration?
Yes in most states under the ESIGN Act (15 U.S.C. §7001) and UETA where adopted, but check local exceptions for wills and certain court filings; confirm the receiving institution accepts electronic execution.
Are witnesses always required?
Witness requirements vary by state. Some states require two witnesses for durable POAs (for example Florida); others accept notarization alone. Verify the principal’s state law before execution.
Do banks accept an electronic POA?
Many banks accept notarized or eSigned POAs, but acceptance policies differ; provide bank-specific forms or a notarized original if requested and confirm requirements in advance.
Can I use remote online notarization?
Remote Online Notarization (RON) is permitted in most states with specific identity proofing and recordkeeping rules; verify the state’s permanent RON status and notary requirements.
How do I revoke the Declaration?
Revoke in writing, sign and date the revocation, notify agents and institutions, and record revocation where the original was recorded to ensure third‑party notice.
Which eSignature plan supports notarization or HIPAA?
Plans differ; signNow offers Business, Business Premium, Enterprise, and Site License tiers and supports HIPAA (BAA required) and advanced features on higher tiers.

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