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Indiana statutory life prolonging form
Download the August 2026 Indiana Life Prolonging Procedures Declaration packet, the form set out in Indiana Code § 16-36-4-11, for requesting life prolonging procedures if you later have a terminal condition and cannot speak for yourself. Get the statutory form in editable Word and true fillable PDF. Add the completed sample PDF if you want a filled-in reference.
A state-specific life prolonging procedures declaration packet, reviewed against the current Indiana statute and ready for instant secure access.
Reproduces the IC 16-36-4-11 life prolonging procedures declaration, the Indiana form for requesting life extending treatment in a terminal condition.
Sign before two competent adult witnesses using the printed attestation, or use the optional notary certificate added under IC 16-36-4-8(b)(5).
Download the files, complete them on your own device, then sign before your witnesses or notary. Your personal details are never entered into an online form builder.
This download includes 1 document in editable Word and fillable PDF formats. Use the Word version for editing; the fillable PDF can be completed on screen, then printed and signed.
Review the complete form text below before purchasing. Your licensed download in editable Word and fillable PDF is delivered after checkout.
LIFE PROLONGING PROCEDURES DECLARATION
(State of Indiana · Indiana Code § 16-36-4-11)
Declaration made this ________ day of __________________________ (month, year).
I, ________________________________, being at least eighteen (18) years of age and of sound mind, willfully and voluntarily make known my desire that if at any time I have an incurable injury, disease, or illness determined to be a terminal condition I request the use of life prolonging procedures that would extend my life. This includes appropriate nutrition and hydration, the administration of medication, and the performance of all other medical procedures necessary to extend my life, to provide comfort care, or to alleviate pain.
In the absence of my ability to give directions regarding the use of life prolonging procedures, it is my intention that this declaration be honored by my family and physician as the final expression of my legal right to request medical or surgical treatment and accept the consequences of the request.
I understand the full import of this declaration.
Signed: ___________________________________________________________________________
___________________________________________________________________________________
City, County, and State of Residence
The declarant has been personally known to me, and I believe (him/her) to be of sound mind. I am competent and at least eighteen (18) years of age.
Witness _______________________________________ Date ___________________
Witness _______________________________________ Date ___________________
Optional notary alternative
Publisher's note. Not part of the statutory form. Indiana Code § 16-36-4-8(b)(5) permits this declaration to be signed in the presence of a notary public instead of two witnesses. If you use this option, leave both witness lines blank and sign while the notary is present.
State of _________________, County of _________________________
On _________________, before me, the undersigned notary public, personally appeared __________________________, was identified as the signer, and signed this declaration in my presence.
Signature of notary public: __________________________________________________________
Printed name: _____________________________________________________________________
County of residence: _______________________________________________________________
My commission expires: _________________ Commission number: ______________
Notary seal / stamp area (leave about one inch clear below for the official seal).
Legal currency, verified
This Indiana declaration lets you request life prolonging procedures if you later have a terminal condition and cannot give directions yourself. It is the opposite direction from an Indiana living will. It tracks the statutory form in Indiana Code § 16-36-4-11.
Verified August 2026 against IC 16-36-4-11 and IC 16-36-4-8. The form text has been unchanged since 1993. A properly executed declaration requires the physician to use life prolonging procedures as requested under § 16-36-4-8(g). Sign before two competent adult witnesses age 18 or older or a notary public under § 16-36-4-8(b)(5).
Date and sign the declaration in the presence of two competent witnesses age 18 or older or a notary public. A witness signing this form attests that you are personally known to the witness and appear of sound mind. The additional relationship and estate restrictions that apply to living will witnesses under § 16-36-4-8(c) apply by their terms to living wills under § 16-36-4-10, not to this § 11 form. If you use a notary, leave both witness lines blank and sign while the notary is present.
The form covers the statutory request for life prolonging procedures in a terminal condition, including appropriate nutrition and hydration, medication, comfort care, and other medical procedures needed to extend life, plus declarant signature, residence, two-witness attestation, and an optional notary alternative.
Editable Word and true fillable PDF of the complete Indiana life prolonging procedures declaration. A completed sample PDF is available separately as a filled-in reference. Customer support and lifetime update access are included with your purchase.
This form is not legal advice. Consider speaking with an Indiana attorney about your circumstances.
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Yes. This packet tracks the life prolonging procedures declaration form in IC 16-36-4-11, unchanged since 1993 and verified against the current Indiana Code in August 2026.
Either one works. IC 16-36-4-8(b)(5) requires your signature in the presence of two competent adult witnesses age 18 or older or a notary public. A witness signing this form also attests that you are personally known and appear of sound mind. The additional relationship and estate restrictions in § 16-36-4-8(c) apply by their terms to living will witnesses, not to this form.
A living will under IC 16-36-4-10 directs that life prolonging procedures be withheld or withdrawn in a terminal condition. This declaration under § 16-36-4-11 requests that life prolonging procedures be used. Under § 16-36-4-8(g), a properly executed life prolonging declaration requires the physician to use the procedures as requested.
If you later have an incurable injury, disease, or illness determined to be a terminal condition, it states your request for life prolonging procedures that would extend your life, including appropriate nutrition and hydration, medication, comfort care, and other medical procedures needed to extend life or alleviate pain.
Both contain the same form text. Use Word to edit the document or the fillable PDF to complete fields on screen. Print the finished form and sign before two witnesses or a notary. Your purchase includes customer support for the download and lifetime update access when we revise the form.