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_________________________ __/__/__

(Testator) Dated

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In the name of Allah, Most Gracious, Most Merciful

HEALTH CARE PROXY AND LIVING WILL

OF

I, ____________________________________, residing at _____________________________, City

_________________________, County _________________________, in the State of

_________________________, being of sound mind and memory do hereby revoke any and all Health Care

Proxy and Living Will and declare this to be my Last Health Care Proxy and Living Will.

If the time comes when I am incapacitated to the point where I 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. This Health Care Proxy and Living Will shall take effect if and when I become unable

to make my own health care decisions

I ask my relatives and friends, whether they believe as I believe or not, to honor my right to these beliefs. I ask

them to honor this document and not to obstruct it or change it in any way. Rather, let them see that my wishes

are executed as I express in this document.

Article I. EXECUTOR

I hereby nominate and appoint _________________________________________________ to be the executor

of my Health Care Proxy and Living Will. In the event that _________________________ predeceases me or

shall be unable or unwilling to act as executor of this Will, I nominate and appoint

_________________________________________________ to act as executor of this Will. I direct that no

bond or surety for any bond be required for executor of this will in performance of his or her duties. The

executor of my Health Care Proxy and Living Will shall hereafter be referred to as my agent

Article II. MEDICAL CARE

In respect of each decision made for me by my agent, it is my wish and direction that my agent be guided solely

by my agent’s Islamic faith 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 withheld from me unless such a treatment 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, only when

medically necessary, in a judicious manner, and its use discontinued, at the discretion of my agent when it is

apparent that there are no chances of survival and/or when there is no brain activity as detected by standard

medical procedure. The “life support systems” include but are not limited to artificial respiration,

cardiopulmonary resuscitation, and artificial means of providing nutrition and hydration and any pharmaceutical

drugs.

I direct that my family, physicians, hospitals and other health care providers and any court or judge honor the

decision of my agent. This request is made, after careful reflection, while I am of sound mind.

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Health Care Proxy and Living Will of _________________________ (continued) Page 2 of 2

Article III. ARBITRATION

In case of dispute, in executing this Will, I appoint and nominate

_________________________________________________ as the arbitrator, who shall strictly adhere to

the Islamic Law in resolving the dispute. If _________________________ predeceases me or is unable or

unwilling, I nominate and appoint _________________________________________________ as the

arbitrator. If ____________________________ also predeceases me or is unable or unwilling, I nominate and

appoint the Imam or a person authorized by the Islamic organization _________________________ located at

_________________________ as the arbitrator. The decision of the arbitrator shall be binding on all the

disputed parties.

Article IV. SEPARABILITY

I direct that if any part of my Health care Proxy and Living Will is determined invalid by a court of competent

jurisdiction, the other parts shall remain valid and enforceable.

Thus done, read and signed at ______________________________ on this the _____ day of _________,

year _____, with Allah as my witness and in the presence of the witnesses and the Notary Official.

_________________________

Signature of Testator

This Will was received, read and signed by the testator and the undersigned witnesses at one time,

without interruption and without turning aside to any other act.

Witness 1 _________________________

(Signature)

_________________________

(Name)

_________________________

(Address)

_________________________

(City, State, Zip)

Witness 2 _________________________

(Signature)

_________________________

(Name)

_________________________

(Address)

_________________________

(City, State, Zip)

Witness 3 (Optional)

_________________________

(Signature)

_________________________

(Name)

_________________________

(Address)

_________________________

(City, State, Zip)

Notary:

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Health Care Proxy and Living Will of _________________________ (continued) Page 3 of 2

Subscribed and sworn to and affirmed before me at ______________________________ on this the _____ day

of _________, year _____

___________________________________

(Signature of Notary)