Georgia

State of Georgia County of _______________ Before me, the undersigned authority, on this day personally appeared {testatorName}, _______________, and _______________, known to me to be the testator and the witnesses, respectively, whose names are subscribed to the annexed or foregoing instrument in their respective capacities, and all of said individuals being by me duly sworn, {testatorName}, testator, declared to me and to the witnesses in my presence that said instrument is the last will and testament or a codicil to the last will and testament of the testator and that the testator had willingly made and executed it as a free act and deed for the purposes expressed therein. The witnesses, each on oath, stated to me in the presence and hearing of the testator that the testator had declared to them that said instrument is the testator's last will and testament or a codicil to the testator's last will and testament and that the testator executed it as such and wished each of them to sign it as a witness; and upon their oaths each witness stated further that they did sign the same as witness in the presence of the testator and at the testator's request; that the testator was 14 years of age or over and of sound mind; and that each of the witnesses was then at least 14 years of age. __________________________________ {testatorName}, Testator __________________________________ Witness __________________________________ Witness Sworn to and subscribed before me by {testatorName}, testator, and sworn to and subscribed before me by the witnesses, this _____ day of ______________, 20____. __________________________________ (Seal) Notary Public, State of Georgia My commission expires: _____________

IMPORTANT INFORMATION This power of attorney authorizes another person (your agent) to make decisions concerning your property for you (the principal). Your agent will be able to make decisions and act with respect to your property (including your money) whether or not you are able to act for yourself. The meaning of authority over subjects listed on this form is explained in O.C.G.A. Chapter 6B of Title 10. This power of attorney does not authorize the agent to make health care decisions for you. You should select someone you trust to serve as your agent. Unless you specify otherwise in the Special Instructions, generally the agent's authority will continue until you die or revoke the power of attorney or the agent resigns or is unable to act for you. Your agent is not entitled to any compensation unless you state otherwise in the Special Instructions. Your agent shall be entitled to reimbursement of reasonable expenses incurred in performing the acts required by you in your power of attorney. This form provides for designation of one agent. If you wish to name more than one agent, you may name a successor agent or name a co-agent in the Special Instructions. Co-agents will not be required to act together unless you include that requirement in the Special Instructions. If your agent is unable or unwilling to act for you, your power of attorney will end unless you have named a successor agent. You may also name a second successor agent. This power of attorney shall be durable unless you state otherwise in the Special Instructions. This power of attorney becomes effective immediately unless you state otherwise in the Special Instructions. If you have questions about the power of attorney or the authority you are granting to your agent, you should seek legal advice before signing this form.

1. Part 1: Health Care Agent 2. Part 2: Treatment Preferences 3. Part 3: Guardianship 4. Part 4: Effectiveness and Signatures

Under O.C.G.A. § 31-32-7(e)(1), a Georgia health-care agent may consent to or refuse most medical care and procedures, but NOT psychosurgery, sterilization, or involuntary hospitalization or treatment under Title 37 (mental-health code). These specific decisions cannot be delegated through the advance directive and must be made by the declarant or, where allowed, through separate judicial process.