I, Declarant's name presently live at street address , City Michigan, zip code. I am of sound mind and voluntarily make this designation.

I designate my representative  to make medical decisions for me, including what doctors I will see, whether to have surgery, what medications to take and other medical decisions that need to be made. I expect my representative  to confer with me before making any of these decisions.

I also designate my representative to make decisions for me regarding where I will live and any other decisions about living arrangements that need to be made. S/he may also make decisions about whether to release records and s/he is authorized to see and have copies of my records from hospitals, clinics, or any program that has my records. I would like my representative to be involved in any meetings about my living arrangements or programs in which I may participate. I expect my representative to confer with me before making any of the above decisions.

This document is not intended to include decisions to withdraw or withhold treatment that would allow me to die. I have signed a separate document to cover those decisions under the Patient Advocate Statute regulated by Michigan law. (MCI.700.4396)   I understand that I may change my mind at any time and destroy this document or draft a new document making other designations. If I become incapacitated, I would like this designation to continue.

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Witnesses Statement: this declaration was signed in our presence. The declarant appears to be making this designation voluntarily, without duress, fraud, or undue influence.

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