Fill and Sign the Durable Power of Attorney for Health Care Decisions Iowa Association Form

Declaration of Gift Over Several Year Period I, ________________________ (name of donor) and ______________________ (name of spouse) of ___________________________________________________________ _______________________ (street address, city, county, state, zip code), desire to give the cash totaling $______________to _________________________ (name of donee) of _______ ____________________________________________________________________________ (street address, city, county, state, zip code, in consideration of our love and affection for him/her and intending to be legally bound to make said payments. Said payments will be in the amounts and on the dates as set forth below: __________________ (Cash Amount) _______________________ (Date) __________________ (Cash Amount) _______________________ (Date) __________________ (Cash Amount) _______________________ (Date) __________________ (Cash Amount) _______________________ (Date) __________________ (Cash Amount) _______________________ (Date) __________________ (Cash Amount) _______________________ (Date) Notwithstanding the foregoing, should _________________________ (name of donee) depart this life prior to receiving all of said payments, the remainder of said payments will be made in the amounts and on the dates set forth above to the executor or other legal representative of _________________________ (name of donee) to be included in the estate of ______________________ (name of donee). The undersigned ________________________ (name of spouse) and _____________________ (name of donor) do hereby consent to have the cash gifts made by us to during the calendar years set forth above considered as made one-half by each of us. Witness our signatures this the _____ day of ___________________, 20____. ____________________________ __________________________ (Name of Donor)
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