WITNESSES On this day, ____________________________date of ________________________________________, the undersigned declared to us that this instrument was his/her Will and requested us to act as witnesses to it. He/She thereupon signed this Will in our presence, all of us being present at the same time. We now, at his/ her request, in his/her presence, and in the presence of each other, subscribe our names as witness and declare that we understand this to be his/her Last Will, and that, to the best of our knowledge the testator is of the age of majority, or is otherwise legally empowered to make a Will, and under no constraint or undue influence. Witness 1. ________________________________________________________________________________________________ Name and Signature Witness 2. ________________________________________________________________________________________________ Name and Signature HEALTH CARE PROXY AND LIVING WILL If the time comes when I am incapacitated and can no longer actively take part in decisions for my own life and am unable to direct my physician as to my own medical care, I wish this statement to stand as a testament of my wishes. I, ________________________________________________________________________________________ hereby appoint the following individual as my health care agent. Name: ____________________________________Phone#________________________________ Address: ________________________________________________________________________________________________ This health care proxy shall take effect if and when I become unable to make my own health care decisions. In respect of each decision made for me by my agent, it is my wish and direction that my agent be guided solely by Islamic Shariah as to what my own decision would have been in the same circumstances. Without limiting the unrestricted scope of my agent’s authority hereunder, I expressly authorize my agent to direct that no treatment be conducted or withheld from me if to do so is against the teachings of Islam, to the best of understanding of my agent. I direct that medication be judiciously administered to me to alleviate pain. I do not intend any direct taking of my life. I also direct that “life support systems” may be used in a judicious manner and its use discontinued, just like any other medicine, if it becomes reasonably apparent that it has no curative value. The “life support systems” include but are not limited to artificial respiration, cardiopulmonary resuscitation, artificial means of providing nutrition and hydration, and any pharmaceutical drugs. I direct that my family, all physicians, hospitals and other health care providers and any court or judge honor the decision of my agent/alternate agent. This request is made, after careful reflection, while I am of sound mind. Name:__________________________________________Signature:___________________________________________________ Witness 1. __________________________________________________________________________________________________ Name and Signature Witness 2. __________________________________________________________________________________________________ Name and Signature ***OPTIONAL*** Subscr ibed and sworn to before me this_______________day of ___________, ___________________ Notary Publ ic ___________________________________________________________Signature & Seal In Case of Emergency Contact: (Include Mosques and all phone numbers) ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ We hope this will benefit you and your family. For a will to be legal in most states, you have to be at least 18 years old and of sound mind. The will must be signed by you and witnessed by two people who won’t receive anything from your estate. However, please consult with an Islamic Scholar and/ or an attorney first. As always, please feel free to pass or share this information on to your friends and other Muslims. Pray for the people at The Islamic Bulletin who prepared this sample Will for you. Jazakum Allahu Khairan (May Allah Reward You). If you want a copy in Arabic, French, Spanish, or need more copies are needed please go to: www.islamicbulletin.org and click on enter here and then Islamic Last Will. For a list of mosques click mosques under enter here. You can print the whole mosques in a PDF format. Rev. 2008 For More Information Please Contact: The Islamic Bulletin , P.O. Box 410186, San Francisco, CA 94141-0186 Web: www.islamicbulletin.org E-Mail: info@islamicbulletin.org THIS INFORMATION IS REQUIRED FOR THE DEATH CERTIFICATE: Full Name ___________________________________________________________________________ Date Of Birth _______________________Place Of Birth ______________________________________ Social Security Number ___________________________________Race _________________________ Street Address And Zip _________________________________________________________________ City/Town Of Residence_______________ County Of Residence_______________________________ Full Name Of Father __________________________________________________________________ First And Maiden Name Of Mother ______________________________________________________ Highest Level Of Education In Years Elementary/Secondary (0-12) _____________ College (1-4 Or 5+) _____________________________ Marital Status (Circle): Never Married Married Widowed Divorced If Married Or Widowed, Name Of Spouse _______________________________________________ Usual Or Last Occupation ___________ Kind Of Business Or Industry__________________________ Name Of Attending Physician _________________________________________________________ Next of Kin and Contact info:_____________________________________________________________ THE NET VALUE OF YOUR ESTATE I. ASSETS (Add up what you own and where located) A. Personal Property: 1. Cash ___________________________________Located:_________________________________________ Cash ___________________________________Located:__________________________________________ 2. Savings: ________________________________________Bank___________________________________ Savings: __________________________________________Bank___________________________________ 3. Checking: ___________________________________Bank______________________________________ 4. Other : _________________________________________________________________________________ 5. Interest in Prof i t Shar ing, Stock, Par tnership, etc.__________________________________________________ 6. Automobi les , Jewel ry, Household & Clothing____________________________________________________ 7. Miscel laneous____________________________________________________________________________ B. Real Estate (describe for each property you own) Value______________________________________________________Located______________________________________ Value______________________________________________________Located_____________________________________ Total Value of al l the above assets: ______________________________________________________________ II. LABILITIES (add what you owe) 1. Money Owed to________________________________________$_________________________________ Address and Phone: _________________________________________________________________________ 2. Money Owed to________________________________________$_________________________________ Address and Phone: _________________________________________________________________________ 3. Money Owed to_______________________________________$__________________________________ Address and Phone: _________________________________________________________________________ 4. Mor tgage______________________________________________________________________________ 5. Personal debts: ( loans , car , etc. )______________________________________________________________ Total Amount owed:________________________________________________________________________ Safe Deposi t Box_______________________ located at __________________________________________ Passpor t # &Type __________________________ Impor tant Passwords #: ___________________________ This document, comprising ________pages, is made in _______ copies. The original is with me, One copy is deposi ted wi th ________________________________________________ Name and Phone # and one copy wi th _______________________________________________________ Name and Phone #
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