Appendix Form #12

• Author: Jerold I. Horn
• Pages: 881-882

Appendix Form #12

[Power of Attorney for health care. Designed to promote ultimate

flexibility.]

Power of Attorney

I, JOHN X. STEVENS, of Peoria, Illinois, appoint my wife,

JANE H. STEVENS, or, if she is unable or unwilling to serve, my

daughter, AMY B. STEVENS, to be my attorney-in-fact (“Agent”)

to act for me and in my name (in any way I could act in person) to

make any and all decisions for me concerning my personal care,

medical treatment, hospitalization and health care and to require,

withhold or withdraw any type of medical treatment or procedure,

even though my death may ensue. My Agent shall have the same

access to my medical records that I have, including the right to

disclose the contents to others. My Agent also shall have full power

to direct the disposition of my remains.

I intend hereby to confer upon the Agent the most

comprehensive powers possible for me to give in connection with

the foregoing.

I signed this Power of Attorney this February 15, 2014.

_____________________

JOHN X. STEVENS

The principal has had an opportunity to review the above form

and has signed the form or acknowledged his or her signature or

mark on the form in my presence. The undersigned witness certifies

that the witness is not: (a) the attending physician or mental health

service provider or a relative of the physician or provider; (b) an

owner, operator or relative of an owner or operator of a health care

facility in which the principal is a patient or resident; (c) a parent,

sibling, descendant or any spouse of such parent, sibling or

descendant of either the principal or any agent or successor agent

under the foregoing power of attorney, whether such relationship is