Illinois Living Will Template
This Illinois Living Will is a legal document that outlines your wishes regarding medical treatment in the event that you are unable to communicate them yourself. It is in compliance with the Illinois Living Will Act (755 ILCS 35/).
Personal Information
- Full Name: ___________________________
- Address: _____________________________
- City: _______________________________
- State: Illinois
- Zip Code: ___________________________
- Date of Birth: ________________________
- Social Security Number: ________________
I, _____________________ (full name), being of sound mind, willfully and voluntarily make known my desire that my dying not be artificially prolonged under the circumstances set forth below, and I declare:
- If at any time I should have an incurable and irreversible condition that will cause my death within a relatively short time, I direct that I be allowed to die and not be kept alive through life-sustaining treatments, including but not limited to artificial respiration, cardiopulmonary resuscitation (CPR), and artificial means of nutrition and hydration.
- If I am unable to communicate my medical treatment preferences, either directly or through a designated health care agent, then I wish my instructions in this living will to stand as my final wishes.
Designation of Health Care Agent
Optionally, you may designate a health care agent who will make health care decisions for you if you are unable. If you choose to do so, provide the information below.
- Health Care Agent Name: ________________________
- Relationship: ________________________________
- Primary Phone Number: _________________________
- Alternate Phone Number: ________________________
This declaration reflects my firm intention to refuse medical treatment under the conditions described herein.
Signed: ________________________________
Date: __________________________________
Witness Declaration
This living will must be signed in the presence of two witnesses who are not related to you by blood or marriage, not entitled to any part of your estate, and not directly financially responsible for your medical care.
Witness #1 Name: ____________________________
Witness #1 Signature: _______________________
Date: ______________________________________
Witness #2 Name: ____________________________
Witness #2 Signature: _______________________
Date: ______________________________________
This document is not valid unless it is signed in the presence of two qualified witnesses. By their signatures, the witnesses affirm that the principal appears to be of sound mind and free from duress at the time of signing.