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Kansas statutory living will
Download the August 2026 Kansas Living Will Declaration, the Natural Death Act form under K.S.A. 65-28,103, for directing that life-sustaining procedures be withheld or withdrawn in a certified terminal condition. Get the form in editable Word and true fillable PDF. Add the completed sample PDF if you want a filled-in reference.
A state-specific living will declaration packet, reviewed against the current Kansas statute and ready for instant secure access.
Built to the declaration content K.S.A. 65-28,103(c) requires, with the statutory body, optional additional directions, and both statutory execution paths, not a generic national template.
Editable Word and true fillable PDF, with stacked house execution blocks and a completed sample available as a reference.
Complete the form on your device, then sign with two qualifying witnesses or a 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 Word and fillable PDF download is delivered after checkout.
KANSAS LIVING WILL DECLARATION
(Kansas Natural Death Act · K.S.A. 65-28,103)
Note to Declarant: Any adult person may execute a declaration directing the withholding or withdrawal of life-sustaining procedures in a terminal condition. A declaration made pursuant to K.S.A. 65-28,103 must be: (1) in writing; (2) signed by the person making the declaration, or by another person in the declarant's presence and by the declarant's expressed direction; (3) dated; and (4) (A) signed in the presence of two or more witnesses at least 18 years of age neither of whom shall be the person who signed the declaration on behalf of and at the direction of the person making the declaration, related to the declarant by blood or marriage, entitled to any portion of the estate of the declarant according to the laws of intestate succession of this state or under any will of the declarant or codicil thereto, or directly financially responsible for declarant's medical care; or (B) acknowledged before a notary public. The declaration of a qualified patient diagnosed as pregnant by the attending physician shall have no effect during the course of the qualified patient's pregnancy.
It shall be the responsibility of declarant to provide for notification to the declarant's attending physician of the existence of the declaration. An attending physician who is so notified shall make the declaration, or a copy of the declaration, a part of the declarant's medical records.
The declaration shall be substantially in the following form, but in addition may include other specific directions. Should any of the other specific directions be held to be invalid, such invalidity shall not affect other directions of the declaration which can be given effect without the invalid direction, and to this end the directions in the declaration are severable.
DECLARATION
Declaration made this __________ day of __________________ (month, year).
I, ____________________________________, being of sound mind, willfully and voluntarily make known my desire that my dying shall not be artificially prolonged under the circumstances set forth below, do hereby declare:
If at any time I should have an incurable injury, disease, or illness certified to be a terminal condition by two physicians who have personally examined me, one of whom shall be my attending physician, and the physicians have determined that my death will occur whether or not life-sustaining procedures are utilized and where the application of life-sustaining procedures would serve only to artificially prolong the dying process, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication or the performance of any medical procedure deemed necessary to provide me with comfort care.
In the absence of my ability to give directions regarding the use of such life-sustaining procedures, it is my intention that this declaration shall be honored by my family and physician(s) as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences from such refusal.
I understand the full import of this declaration and I am emotionally and mentally competent to make this declaration.
Optional additional specific directions (if any):
________________________________________________________________________
________________________________________________________________________
__________________________________________
Signature of Declarant
__________________________________________
Printed Name of Declarant
__________________________________________
City, County and State of Residence
The declarant has been personally known to me and I believe the declarant to be of sound mind. I did not sign the declarant's signature above for or at the direction of the declarant. I am not related to the declarant by blood or marriage, entitled to any portion of the estate of the declarant according to the laws of intestate succession or under any will of declarant or codicil thereto, or directly financially responsible for declarant's medical care.
First Witness
__________________________________________
Signature of First Witness
__________________________________________
Printed Name of First Witness
__________________________________________
Street Address
__________________________________________
City, State, ZIP
Second Witness
__________________________________________
Signature of Second Witness
__________________________________________
Printed Name of Second Witness
__________________________________________
Street Address
__________________________________________
City, State, ZIP
(OR)
Notary Acknowledgment
STATE OF __________________
COUNTY OF __________________
This instrument was acknowledged before me on ________________ (date) by ____________________________ (name of person).
____________________________________
Signature of Notary Public
(Seal, if any)
My appointment expires: __________________
Copies
Legal currency, verified
This Kansas form lets an adult direct that life-sustaining procedures be withheld or withdrawn in a certified terminal condition under the Kansas Natural Death Act, K.S.A. 65-28,101 through 65-28,109.
Tracks the statutory declaration form in K.S.A. 65-28,103(c), including the pregnancy limitation and the two-physician terminal-condition trigger. Verified August 2026 against the Kansas Revisor of Statutes text. History through L. 1994, ch. 224, § 2. It is not a government publication.
Sign and date before two qualifying adult witnesses, or acknowledge the declaration before a notary public. Either path satisfies K.S.A. 65-28,103(a)(4). Witnesses must not be related by blood or marriage, entitled to your estate, or directly financially responsible for your medical care.
The statutory declaration body, optional additional directions lines, stacked declarant and witness execution blocks, the notary acknowledgment alternative, and the statutory Copies heading. A completed sample PDF is available separately as a filled-in reference.
Editable Word and true fillable PDF of the complete Kansas living will declaration. Customer support and lifetime update access are included with your purchase. The separate Kansas Durable Power of Attorney for Health Care Decisions is not included.
This form is not legal advice. Consider speaking with a Kansas licensed attorney about your situation.
ILRG is committed to top quality legal forms that are valid in all states. If you are not 100 percent satisfied after purchase, contact us for a full refund.
Yes. K.S.A. 65-28,103 requires the declaration to be substantially in the statutory form. This packet is designed to match that statutory text. It is not a government publication.
You sign and date the declaration. Then either two qualifying adult witnesses sign, or you acknowledge the declaration before a notary public. Either path satisfies K.S.A. 65-28,103(a)(4).
A witness must be at least 18 and must not be the person who signed for you, related to you by blood or marriage, entitled to any portion of your estate, or directly financially responsible for your medical care.
When two physicians who have personally examined you, including your attending physician, certify a terminal condition and determine that death will occur whether or not life-sustaining procedures are used.
Yes. The declaration of a qualified patient diagnosed as pregnant by the attending physician has no effect during the course of that pregnancy.
No. This declaration states treatment directions only. To name a decision maker, use the separate Kansas Durable Power of Attorney for Health Care Decisions.