State of California File # ______________________________ Secretary of State REGISTRATION OF WRITTEN ADVANCE HEALTH CARE DIRECTIVE (Probate Code sections 4800-4805) IMPORTANT - Read all instructions before completing this form. This Space For Filing Use Only 1. CHECK THE APPLICABLE BOX (NOTE: CHECK ONLY ONE BOX) New Registration.............. For a new registration, check this box and complete the entire form. There is a $10.00 filing fee for registration of a new directive. Amendment...................... For an amendment to a previously filed registration form (not the directive), check this box, complete Items 3 and 7 and the appropriate section that changed. There is no filing fee. Revocation Only...............For a revocation (change) of a written advance health care directive that has been registered previously with the Secretary of State or a revocation of your registration, check this box and complete Items 3 and 7. There is no filing fee. Revocation (change) ........ For a revocation (change) of a written advance health care directive that has been registered previously and the registration of a new directive, check this box and complete the entire form. There of Prior Directive and New Registration is a $10.00 filing fee for registering the new directive. 2. CHECK THE APPLICABLE STATEMENT(S): The written advance health care directive is attached This serves as notification of intended place of deposit or safekeeping of a written advance health care directive 3. REGISTRANT’S INFORMATION: NAME (LAST) (FIRST) (MIDDLE) STREET ADDRESS CITY AND STATE ZIP CODE DATE OF BIRTH PLACE OF BIRTH ENTER AT LEAST ONE ITEM: a. Social Security Number b. Driver’s License Number and State or Country Issuing c. Other Identifying Number Established By Law and State or Country Issuing 4. AGENT INFORMATION (if any): NAME (LAST) (FIRST) HOME TELEPHONE NUMBER WORK TELEPHONE NUMBER ( ( ) (MIDDLE) ) 5. ALTERNATE AGENT INFORMATION (if any): NAME (LAST) (FIRST) HOME TELEPHONE NUMBER WORK TELEPHONE NUMBER ( ( ) (MIDDLE) ) 6. INTENDED PLACE OF DEPOSIT OR SAFEKEEPING OF THE WRITTEN ADVANCE HEALTH CARE DIRECTIVE (if applicable): 7. SIGNATURE OF REGISTRANT DATE TYPE OR PRINT NAME OF REGISTRANT SFL-461 (REV 06/2006) APPROVED BY SECRETARY OF STATE American LegalNet, Inc. www.USCourtForms.com INSTRUCTIONS Registering a written advance health care directive (directive) or its location is voluntary . Registration or failure to register does not affect the validity of the directive. A directive or information regarding the location of a directive may be filed with the Secretary of State pursuant to Probate Code sections 4800-4805 by using this form. If any information on the registration form changes, or if the actual directive is revoked (changed), the registrant must complete and submit this form to the Secretary of State. A registrant must re-register upon execution of a subsequent directive. 1. If this is a new registration of your directive, check the New Registration box on the form and complete the entire form. Attach to the form a check payable to the Secretary of State in the amount of $10.00 and mail the check and completed form to the address below. If this is an amendment or change to a registration form that you have previously filed with the Secretary of State (for example, a change of address or a change in the location of your directive), check the Amendment box on the form, complete Items 3 and 7, and provide the information that changed in the applicable section. There is no filing fee. Mail the completed form to the address below. If this is notification that your directive previously registered with the Secretary of State has been revoked or has changed, and you are not registering a new directive with the Secretary of State, OR if you want to revoke your prior registration of your directive with the Secretary of State, check the Revocation Only box on the form and complete Items 3 and 7. There is no filing fee. Mail the completed form to the address below. If this is notification that your directive previously registered with the Secretary of State has been revoked or has changed, and you want to register a new directive with the Secretary of State, check the Revocation (change) of Prior Directive and New Registration box on the form and complete the entire form. Attach to the form a check payable to the Secretary of State in the amount of $10.00 for the new registration and mail the check and completed form to the address below. 2. Check the appropriate statement indicating if your directive is attached to this form or if you are providing the location of the directive. 3. Print your name, address, date of birth and place of birth. Also include at least one of the following: social security number, driver’s license number and state or country of issuance, or another form of identification issued by a government agency. The identification numbers will not be disclosed to the public; however, they will be used by this office to ensure the correct information for the correct person is provided to your health care provider when requested. 4. Print the full name and telephone number of your agent, if any, who is authorized to make health care decisions for you as indicated in your directive. 5. Print the full name and telephone number of your alternate agent, if any, who is authorized to make health care decisions for you as indicated in your directive. 6. Provide the address or location of the directive (e.g. safe in the closet in the spare room at 123 Any Street, Any City, CA 99999) if this is the purpose of the registration. 7. Sign, date and type or print your name below. If you are unable to fill out or sign the form, another adult can complete it in your presence and at your direction. (2 Cal. Code of Regs. section 22610.2(a)) Mail the completed form and any applicable filing fees to: Secretary of State, Special Filings Unit, P.O. Box 942877, Sacramento, CA 94277-0001 (916) 653-3984 Pursuant to Probate Code section 4800 and 2 Cal. Code of Regs. section 22610.2, the information on this form is requested by the Secretary of State’s Office, Special Filings Unit, P.O. Box 942877, Sacramento, CA 94277-0001, Telephone number (916) 653-3984. Providing the information is necessary in order to identify you should there be a request to receive information as specifically authorized by law. Information received on lines 3(a), 3(b), and 3(c) of the form will not be disclosed except as specifically authorized by law, although at least one of the items must be provided by you for identification purposes. SFL-461 (REV 06/2006) APPROVED BY SECRETARY OF STATE American LegalNet, Inc. www.USCourtForms.com