Registration Form

REGISTRATION FORM Instructions: Please complete the information requested below and mail to the address listed above. A registry card containing an file number and password will be sent to you. Please carry the card with you at all times and furnish the file number and password to persons who need to be aware of your directives, such as family members and health care providers. PLEASE TYPE OR PRINT. COMPLETE LINES 1 THROUGH 4. 1.2.Social Security #: (OPTIONAL**)3.4.City: Zip If you are an attorney filing on behalf of the Registrant above, please provide your name and mailing address should you wish the documents returned to your attention. City Zip The fee for each directive to be registered is $10.00. Check the directive you have enclosed with this form: A health care power of attorney; A declaration of a desire for a natural death; An advance instruction for mental health treatment; or A declaration of an anatomical gift. **The Advance Health Care Directive Registration requests submission of the social security number as a part of the confidential registration process. Please note that while we request this data, all health care directives and social security numbers are unavailable to the public. Provision of the social security number will allow anyone who has your unique identifying code and password to have access to any and all documents you file with this agency. If you choose not to provide the social security number, then you will be provided a wallet size card with a unique identifying number and password for each document you file. NORTH CAROLINA SECRETARY OF STATE Advance Health Care Directive Registry P. O. Box 29622 Raleigh, NC 27626-0622 American LegalNet, Inc. www.FormsWorkFlow.com