Fill and Sign the Legal Regulatory and Policy Frameworks for Organ Donation Form

REVOCATION OF DONATION PURSUANT TO THE REVISED UNIFORM ANATOMICAL GIFT ACT I, ____________________________, Declarant, having made an anatomical gift by virtue of that document of gift dated the ______ day of ____________________________, 20______, do hereby revoke such gift pursuant to KRS 311.1919 which provides that an anatomical gift may be revoked as follows: (1)(a) A record signed by: 1. The donor; 2. The other person; or 3. Subject to subsection (2) of this section, another individual acting at the direction of the donor or the other person if the donor or other person is physically unable to sign; or (b) A later-executed document of gift that amends or revokes a previous a natomical gift or portion of an anatomical gift, either expressly or by inconsistency. (2) A record signed pursuant to subsection (1)(a)3. of this section shall: (a) Be witnessed by at least two (2) adults, at least one (1) of whom is a disinterested witness, who have signed at the request of the donor or the other person; and (b) State that it has been signed and witnessed as provided in paragraph (a) of this subsection. (3) Subject to KRS 311.1923, a donor or other person authorized to make an anatomical gi ft under KRS 311.1915 may revoke an anatomical gift by the destruction or cancell ation of the document of gift, or the portion of the document of gift used to make the gif t, with the intent to revoke the gift. (4) A donor may amend or revoke an anatomical gift that was not made in a will by any form of communication during a terminal illness or injury addressed to at lea st two (2) adults, at least one (1) of whom is a disinterested witness. (5) A donor who makes an anatomical gift in a will may amend or revoke the gift in the manner provided for amendment or revocation of wills or as provided in subsect ion (1) of this section. This is my written revocation of my anatomical gift and is provided t o all persons to whom I have provided a copy of my document of anatomical gift. DATED this the ______ day of ____________________________, 20______. Signature of Declarant: __________________________________________________________ Printed Name of Declarant: ____________________________ Address of Declarant: ____________________________ WITNESS FORM The witnesses below declare that they are signing at the dir ection of the declarant after having witnessed the signature of the declarant, have no interest in the es tate of the declarant under the laws of intestate succession or any will or the declarant or codic il thereto, and are not financially responsible for the declarant’s care. Witness Signature: ________________________________________________________ Witness Name: Address: Witness Signature: ________________________________________________________ Witness Name: Address: ACKNOWLEDGEMENT FORM State of Judicial District The foregoing instrument was acknowledged before me this (date) by . (name of person who acknowledged). Signature of Person Taking Acknowledgement: _______________________________________________ Title or Rank: Serial Number, if any: