Mandate in
Anticipation of Incapacity



By these presents, I, ________________________________________, (Occupation)_______________________________________, (Address)________________________________________________________, being of full age and sound mind, wish to make provision in the event that I become unable to care for myself or administer my affairs subsequent to an illness, deficit, or weakening due to my age that alters my mental faculties or physical abilities to the point where I am no longer able to express my wishes.

If I become incompetent in the manner described above, I appoint ______________________________________, (Occupation)________________________________, (Address)____________________________________________________________________ to represent me and to act according to my wishes expressed herein. If, when I become incompetent, this person has died, has resigned, or is unable to act, I appoint _________________________________, (Occupation)______________________, (Address)__________________________________ to replace him or her.
  1. Where the protection of my person is concerned, I ask my mandatary to take any action, make any decision, give any consent and authorization and generally represent me to the best of my interests, in order to protect me and generally ensure my physical, moral, and material well-being. Notwithstanding the generality of the foregoing, I give the following specific instructions:

    _______________________________________________________________________

    _______________________________________________________________________

    _______________________________________________________________________

    Moreover, should a situation arise where I have become mentally and physically incompetent and there is no reasonable hope of my recovery, I ask that sufficient medication be administered to relieve my suffering and, if the case may be, that I be allowed to die without recourse to artificial means of life support. To the extent possible, I wish to avoid a diminishing of my dignity caused by degradation, dependency, and unnecessary suffering. To this effect, I specifically give the following instructions:

    _______________________________________________________________________

    _______________________________________________________________________

    _______________________________________________________________________
  2. I authorize my mandatary to administer my moveable and immoveable property, as defined in the Civil Code of Québec so long as there is reasonable hope that I may recover competency. If, however, in the formal opinion of the health professionals who have assessed my case, there is no reasonable hope of my recovering competency, my mandatary shall, upon confirmation of this state of affairs, have full administration of my property, with the exception that he or she shall only make sound investments as defined in the Civil Code of Québec. I request that my mandatary administer my property prudently and, in the event that expert counsel is required, I authorize him or her to seek legal or other counsel that he or she deems necessary, at my expense. In addition to the preceding instructions, I wish my mandatary to respect the following wishes in the administration of my affairs:

    _______________________________________________________________________

    _______________________________________________________________________

    _______________________________________________________________________

    When he or she begins executing his or her mandate, my mandatary should make an inventory of all of my property, for administration purposes, but without submitting to the formalities of the Civil Code of Québec. He or she does not have to make a detailed inventory of my moveable property that is of little value.

  3. To thank and reimburse him or her for executing his or her mandate, and in addition to reimbursement of any reasonable expenses he or she may incur, I give my mandatary the following compensation:

    _______________________________________________________________________

    _______________________________________________________________________

    _____________________________________________________________________

    In witness whereof I have signed this ________ day of ______________ 19____.


    ____________________________________
    (Signature)


MANDATORY DECLARATION OF THE WITNESSES

This page was signed and the preceding pages were initialled by the Mandator, who publishes and declares this document as his Mandate in Anticipation of the Mandator's Incapacity. This signature and this declaration were made in our joint presence. We declare that at the time of these signatures, the Mandator appeared to be in full possession of his mental faculties. We so certify by our signatures.


_____________________________________
(Witness name)

_____________________________________
(Occupation)

_____________________________________
(Address)

_____________________________________



_____________________________________
(Witness name)

_____________________________________
(Occupation)

_____________________________________
(Address)

_____________________________________



ACCEPTANCE OF MANDATE

I, _________________________________________________________,

(Occupation) _________________________________, (Address)____________________________________________________declare that I have read the Mandate that I am being asked to assume and that I understand its nature, as well as the obligations deriving therefrom. I accept this Mandate and agree to take the necessary steps to ensure that it is validated at the appropriate time, as provided by law.


In witness whereof I have signed this ___________ day of ______________ 19____.


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