Housing Advance Directive (DRAFT - 4)

This Housing Advance Directive (HAD) is my plan to protect my family, pets, housing and personal property and when I have been involuntarily hospitalized. This HAD is authorized under the Uniform Statutory Power of Attorney (California Probate Code Section 4401) and does not authorize medical or health care decisions.

I, ______________________________________(your name)

appoint the following person(s), who have agreed to make sure my HAD is utilized when I have been hospitalized:

Name_______________________________________________

Address_______________________________________________

______________________________________________________

Phone - Home___________________Work___________________

Cell or Pager____________________Fax_____________________

Email__________________________________________________

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *

Name_______________________________________________

Address_______________________________________________

______________________________________________________

Phone - Home___________________Work___________________

Cell or Pager____________________Fax_____________________

Email__________________________________________________

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *

I have also filed:

_____Advance Directive which will go into effect should I become incapacitated.

_____I. CHILDREN AND DEPENDENTS

a) I have ____ child(ren) or dependents

_____ who reside with me full time

Name:_____________________________

Date of Birth:__________

Name:_____________________________

Date of Birth:____________

I authorize____________________________to have temporary custody of my minor child(ren) and dependents listed below.

Address____________________________

____________________________

Phone ____________________________

b) I have joint custody of _____ child(ren) or dependents who reside with me part time and reside part time with ________________________ who will take custody of my minor child(ren) or dependents.

Address: _____________________

_____________________________

Phone: _______________________

Name:_____________________________(of child or dependent)

Date of Birth:__________

CHILD(REN)'S CARE INFORMATION

Child(ren)'s Health Insurance

Carrier__________________________________

Policy or Account#________________________

Physician Name_______________________________

Address_____________________________________

___________________________________________

Phone#_____________________________________

Child(ren)'s School________________________________

Address_________________________________________

_______________________________________________

Phone#_________________________________________

c) I have _____ child(ren) or dependents who visit me. Please make sure they get home if they are visiting me when I am hospitalized.

Name:_____________________________(of child or dependent)

Address:_____________________________

______________________________

Phone:______________________________

____II. PETS

I have pet(s) (name and type):

______________________________________

______________________________________

That require the following care:

_______________________________________________________________

_______________________________________________________________

Veterinarian's Name____________________________________

Address______________________________________________

____________________________________________________

____________________________________________________

Phone#______________________________

The person below has agreed to care for my pet(s)

_____________________________________________

Address_______________________________________

______________________________________________

Phone_______________________________

____III. MY HOUSING and CAR

Please check to make sure that my housing and/or car are secure.

_____The following person has a spare key(s) to:

_____ my home

_____ my mailbox

_____ my car

Name____________________________________

Address__________________________________

_________________________________________

Phone__________________

_____A Spare key(s) is kept_____________________________________

The above person has my permission to enter my home to: (Initial those that apply.)

Make sure my home is secure -

____the doors locked

____windows closed in bad weather

____open in good weather (specify which ones)___________________________

___________________________________________________________

___Leave a light on (specify)______________________

___Close the curtains or blinds

___Leave curtains or blinds open

___Mail brought in

___Newspapers be brought in

___Other security measure (specify)______________________

Maintenance -

___Turn heat and unnecessary appliances off to save on energy bill

___Refrigerator - check to see if food needs to be thrown out

___Take garbage out

___Make sure there is no water running that needs to be turned off

___Water plants How often?________________________________

The above named person has my permission to enter my car to:

___Park it legally

___Lock the doors

___Turn off motor, lights

_____IV. FINANCIAL

I authorize, ________________________, to utilize funds from my account(s) to be used to:

_____provide adequate and necessary care for my child(ren) and dependents.

_____provide adequate and necessary care for my pets.

_____pay the following bills

____Gas and Electricity

____Garbage

____Water

____pay my rent which is due on the ____of the month to:

Landlord/Manager__________________________________________

Address___________________________________________________

_________________________________________________________

Specify how rent is paid )cash, check, mail, in-person, etc.)__________

_________________________________________________________

Amount_____________

Type of Housing Subsidy (if any)_______________________________

_________________________________________________________

____Condo dues which are due on the ____of the month to:

Check made out to:_________________________________________

Address__________________________________________________

_________________________________________________________

Amount________________

____Mortgage payments

Amount _________due on ____ of the month to:

Name____________________________________________________

Address__________________________________________________

_________________________________________________________

____Other bills (specify)____________________________________________

__________________________________________________________

____Consult me before paying the following bills_________________________

__________________________________________________________

My account#_____________________________________________________ is at (Bank)_________________________________________________________

Address_____________________________________________________

____________________________________________________________

_____pay other financial obligations (specify)______________________________________

I authorize____________________________________to act on my behalf with the Social Security Administration in order to maintain continuity of my benefits

My Social Security Number is___________________________

V. SIGNATURE

I declare that this Housing Advance Directive was developed with my full knowledge and participation and without coercion.

I agree that any third party who receives a copy of this document may act under it. Revocation of this power of attorney will be writing and is not effective as to a third party until the third party has actual knowledge of the revocation. I agree to indemnify the third party for any claims that arise against the third party because of reliance on this power of attorney.

Signed_____________________________________

This_______ day of __________________, 20_____

In the State of ___________________________, County of _________________________

VI. WITNESSES

I declare under penalty of perjury under the laws of California (1) that the individual who signed this Housing Advance Directive is personally known to me, or that the individual's identity was proven to me by convincing evidence, (2) that the individual signed or acknowledged this Housing Advance Directive in my presence, (3) that the individual appears to be of sound mind and under no duress, fraud or undue influence, and (4) that I am not appointed as an agent by this Housing Advance Directive.

First Witness Second Witness

______________________________________________ __________________________________________

(Print Name) (Print Name)

______________________________________________ __________________________________________

(Address) (Address)

______________________________________________ __________________________________________

(City, State) (City, State)

______________________________________________ __________________________________________

(Signature) (Signature)

______________________________________________ __________________________________________

(Date) (Date)

-created by the California Network of Mental Health Clients, June 2001