This required section states the basic purpose for this document. It is important for the Principal to understand the rights and duties of all parties before executing this document. Press [Ctrl+F1] for more information.
This required section states the name and address of the person appointed to make health care decisions if the Principal is unable to do so. There are limits on who may act as the Agent. Press [Ctrl +F1] for more information.
This required section states a Durable Power of Attorney for Health Care is created which is effective during the Principal's inability to make decisions regarding health care. Press [Ctrl+F1] for more information.
This is a required section concerning the authority the Agent is given. The Principal grants full power to the Agent to make health care decisions if Principal is unable to do so. Press [Ctrl+F1] for more information.
This optional section states the Principal's wishes regarding life-sustaining mechanisms which artificially postpone death, and desires regarding artificial food and nutrition. Press [Ctrl+F1] for more information.
This optional section gives the Principal the opportunity to include special provisions concerning health care which are not otherwise contained in the document. Press [Ctrl+F1] for more information.
In this optional section the Principal may specify any values or preferences, such as religious beliefs, location of care or personal values, which pertain to this document. Press [Ctrl+F1] for more information.
This optional section enables the Principal to establish specific limitations upon the decision making authority of the Agent. Press [Ctrl+F1] for more information.
This required section enables the Agent to request, review and disclose information regarding the physical and mental condition of the Principal. Press [Ctrl+F1] for more information.
This required section gives the Agent the authority to sign on behalf of the Principal if the Principal is unable to do so. Press [Ctrl+F1] for more information.
This required section enables the Principal to state whether or not the Agent has authority to make anatomical gifts for medical purposes, authorize an autopsy or direct disposition of remains. Press [Ctrl+F1] for more information.
This is a required section which states this document will exist indefinitely unless otherwise specified. Press [Ctrl+F1] for more information.
This is an optional section which states that if the original Agent is not available, an alternate Agent will assume responsibility of the original Agent. Press [Ctrl+F1] for more information.
This required section states that any prior Durable Power of Attorney made by the Principal is revoked. Press [Ctrl+F1] for more information.
This required paragraph states that any person or entity who faithfully carry out the terms and provisions of this document shall not be held liable for any damages which may occur. Press [Ctrl +F1] for more information.
This required paragraph prevents the entire document from being invalidated if any provision of the document is declared invalid. Press [Ctrl+F1] for more information.
This required section states that this document be legally binding and if it is not recognized as a legal document it will be treated as a formal statement of the Principal's desires. Press [Ctrl+F1] for more information.
By signing this required section, the Principal will acknowledge full understanding of the document contents as well as the effects of the granting of powers to the Agent. Press [Ctrl+F1] for more information.
This section requires the signature of two witnesses or a Notary Public to acknowledge that the Principal signed the document. Press [Ctrl+F1] for more information.
This required section provides information regarding the suggested distribution of copies of the Health Care Power of Attorney. Press [Ctrl+F1] for more information.
Times New Roman
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Health Care POA
HCP_MS
The Health Care Power of Attorney is a document under which a competent adult (a Principal), prior to becoming unconscious or incompetent, declares his/her intention that life-sustaining procedures should be withheld or withdrawn under certain circumstances, and designates a person who will have authority to make health care decisions for the Principal, if the Principal is unable to do so.
Enter the name of the person that this document is being created for (the "Principal") or edit the information as desired. Use the P.I. Manager to select and paste a record. Press [Ctrl+F1] for more information.
HMS01
! Disclosure Statement Section (1 of 20)
NOTICE TO PERSON EXECUTING THIS DOCUMENT
This is an important legal document. Before executing this document, you should know these important facts:
This document gives the person you designate as the Attorney-in-Fact (your Agent) the power to make health care decisions for you. This power exists only as to those health care decisions to which you are unable to give informed consent. The Attorney-in-Fact must act consistently with your desires as stated in this document or otherwise made known.
Except as you otherwise specify in this document, this document gives your Agent the power to consent to your doctor not giving treatment or stopping treatment necessary to keep you alive.
Notwithstanding this document, you have the right to make medical and other health care decisions for yourself so long as you can give informed consent with respect to the particular decision. In addition, no treatment may be given to you over your objection, and health care necessary to keep you alive may not be stopped or withheld if you object at the time.
The document gives your Agent authority to consent, to refuse to consent or to withdraw consent to any care, treatment, service or procedure to maintain, diagnose or treat a physical or mental condition. This power is subject to any statement of your desires and any limitations that you include in this document. You may state in this document any types of treatment that you do not desire.
In addition, a court can take away the power of your Agent to make health care decisions for you if your Agent (a) authorizes anything that is illegal, (b) acts contrary to your known desires, or (c) where your desires are not known, does anything that is clearly contrary to your best interests.
You have the right to revoke the authority of your Agent by notifying your Agent or your treating doctor, hospital or other health care provider in writing of the revocation.
Your Agent has the right to examine your medical records and to consent to this disclosure unless you limit this right in this document.
Unless you otherwise specify in this document, this document gives your Agent the power after you die to (a) authorize an autopsy, (b) donate your body or parts thereof for transplant or for educational, therapeutic or scientific purposes, and (c) direct the disposition of your remains.
If there is anything in this document that you do not understand, you should ask your lawyer to explain it to you.
This power of attorney will not be valid for making health care decisions unless it is either (a) signed by two (2) qualified adult witnesses who are personally known to you and who are present when you sign or acknowledge your signature or (b) acknowledged before a Notary Public in the state.
It is important that this section be read in order to understand the purpose of this document, and the rights and obligations of the person making the document (the "Principal") and the person appointed to make health care decisions (the "Agent").
HMS02
! Designation of Health Care Agent Section (2 of 20)
DURABLE POWER OF ATTORNEY FOR HEALTH CARE
!. DESIGNATION OF HEALTH CARE AGENT.
I, !, hereby appoint: (A treating health care provider or an employee of a treating health care provider may not be named as your Attorney-in-Fact.)
Agent Name: !
Agent Address:Street 1: !
Street 2: !
City: !,
State: !
Zip Code: !
! ___________________________________
___________________________________
___________________________________
___________________________________
Country: !
Phone: Home: ! Work: !
Relation, if any: !
as my Attorney-in-Fact to make health care decisions for me if I become unable to give informed consent for my own health care decisions. This document gives my Attorney-in-Fact the power to consent, refuse to consent, or withdraw consent on my behalf for any health care, treatment, service, or procedure to maintain, diagnose, treat a physical or mental condition.
This required section states the name and address of the person appointed as Health Care Agent. The Agent will make health care decisions for the Principal if the Principal is unable to make such decisions. Press [Ctrl+F1] for more information.
Enter the name of the person that this document is being created for (the "Principal") or edit the information as desired. Use the P.I. Manager to select and paste a record. Press [Ctrl+F1] for more information.
Enter the Agent's name or use the P.I. Manager to select and paste a record. Note the limits on who may serve as Agent which appear in this section. The Agent will have the authority to make health care decisions for the Principal if the Principal is unable to do so.
Enter the Agent's street address or edit the information as desired.
Enter the Agent's extended street address or edit the information as desired.
Enter the Agent's city or edit the information as desired.
Enter the Agent's state/province or edit the information as desired. When naming an Agent, consider the availability of the Agent to confer with health care providers and access medical records and information.
Enter the Agent's zip/postal code or edit the information as desired.
Enter an X to include the Agent's country. If the Agent resides in a different country, he/she may not be available to discuss medical decisions with the health care providers.
Enter the country or edit the information as desired.
Enter a phone number where the Agent may be reached during non-business hours.
Enter a phone number where the Agent may be reached during business hours, if different from the home phone number.
Enter the relationship of the Agent to the Principal.
IWY02
! Creation of Durable Power of Attorney for Health Care Section (3 of 20)
!. CREATION OF DURABLE POWER OF ATTORNEY FOR HEALTH CARE. By this document I intend to create a Durable Power of Attorney for Health Care. This power of attorney shall take effect upon my disability, incapacity, or incompetency, and shall continue during such disability, incapacity, or incompetency.
This is a required section stating that a Durable Power of Attorney for Health Care is being created. It shall only be effective during the Principal's inability to make decisions regarding health care. Press [Ctrl+F1] for more information.
HMS04
! Authority of Agent Section (4 of 20)
!. GENERAL STATEMENT OF AUTHORITY GRANTED. Subject to my special instructions below, this document gives my attorney in fact ("agent") the full power to make health care decisions for me, before or after my death, to the same extent I could make decisions for myself and to the full extent permitted by law, including power to grant, refuse or withdraw consent on my behalf for any health care service, to make a disposition under the state's anatomical gift act, to authorize an autopsy, and to direct the disposition of my remains. My Agent also has the authority to talk to health care personnel, get information and sign forms necessary to carry out these decisions, and also the power provided in Sections 41-41-101 through 41-41-121, Mississippi Code of 1972, as now enacted or hereafter amended, being the statutes governing the withdrawal of life-saving mechanisms.
This required section states the general duties and powers of the Agent on behalf of the Principal. The health care decisions made by the Agent must be consistent with the desires of the Principal as stated in this document, or otherwise known to the Agent. Press [Ctrl+F1] for more information.
HMS05
! Optional Life Sustaining Mechanisms Section (5 of 20)
!. STATEMENT OF DESIRES CONCERNING LIFE-SUSTAINING CARE,
TREATMENT, SERVICES AND PROCEDURES: [Select one of 5 choices; last choice allows you to compose your own statement.]
! I specifically direct my Agent to follow any "living will" executed by me.
! I do not want my life to be prolonged nor do I want life-sustaining mechanisms to be provided or continued if my Agent believes the burdens of the treatment outweigh the expected benefits. I want my Agent to consider the relief of suffering, my personal beliefs, the expense involved and the quality as well as the possible extension of my life in making decisions concerning life-sustaining mechanisms.
! I do not want my life to be prolonged and I do not want life-sustaining mechanisms, except to the extent deemed necessary to provide me with comfort care,
! if I have a condition that is incurable or irreversible and, without the administration of life-sustaining mechanisms, expected to result in death within a relatively short time.
! if I am in a permanently unconscious condition which is reasonably concluded to be irreversible.
! if I have a condition that is incurable or irreversible and, without the administration of life-sustaining mechanisms, expected to result in death within a relatively short time, or if I am in a permanently unconscious condition which is reasonably concluded to be irreversible.
! I want my life to be prolonged to the greatest extent possible within the standards of accepted medical practice, without regard to my condition, the chances I have for recovery, or the cost of the procedures.
! [User to compose own statement of desires concerning life-sustaining mechanisms]
! [Optional Nutrition and Fluids Section]
!. STATEMENT OF DESIRES CONCERNING NUTRITION AND FLUIDS. Artificially provided nutrition or fluids provided by means of a nasogastric tube or tube into the stomach, intestines, or veins,
! shall
! shall NOT
be among the "life-sustaining mechanisms" that may be withheld or withdrawn under the conditions given above.
Enter an X to include a section concerning the Principal's wishes regarding life-sustaining mechanisms. States may define this term differently, but generally it means procedures which artificially postpone death. Press [Ctrl+F1] for more information.
Enter an X if the Agent is to follow any "living will" executed by the Principal. A living will is a document under which a competent adult, prior to becoming unconscious or incompetent, declares his/her intention that life-sustaining mechanisms be withdrawn or withheld under certain conditions.
Enter an X if the Principal gives the Agent the discretion to decide if and when the life-sustaining mechanisms may be withdrawn or withheld. The Agent will decide if the burdens of treatment outweigh the benefits.
Enter an X if the Principal desires life-sustaining mechanisms to be given only to the extent of providing the Principal with comfort care.
Enter an X to withhold life-sustaining mechanisms if the condition of the Principal is incurable or irreversible.
Enter an X to withhold life-sustaining mechanisms if the Principal is in a permanently unconscious condition.
Enter an X to withhold life-sustaining mechanisms if the Principal's condition is incurable or if the Principal is in a permanently unconscious state.
Enter an X if the Principal desires every possible procedure to be taken to prolong life to the greatest extent, regardless of cost or chances for recovery.
Enter an X if the Principal desires to compose a separate statement of desires concerning life-sustaining mechanisms. Any of the above statements may be edited or additional statements may be composed.
Use this space to indicate desires concerning life-sustaining mechanisms.
Enter an X to include a section regarding artificially administered nutrition and fluids.
Enter an X if artificial nutrition and fluids SHALL be among the life-sustaining mechanisms that may be withheld or withdrawn by the Agent's authorization.
Enter an X if artificial nutrition and fluids SHALL NOT be among the life-sustaining mechanisms that may be withheld or withdrawn by the Agent's authorization.
IGN06
! Optional Special Provisions Section (6 of 20)
!. SPECIAL PROVISIONS REGARDING MY HEALTH CARE. (For example, describe your wishes regarding any treatment you desire or do not desire, or admission to a residential care facility.)
Enter an X to include a section regarding special provisions concerning health care which are not otherwise contained in the document. For example, describe any types of treatment you wish or wish not to receive. Press [Ctrl+F1] for more information.
Use this space to describe any additional special provisions.
IGN07
! Optional Values and Preferences Section (7 of 20)
!. STATEMENT OF VALUES AND PREFERENCES. (Specify any other wishes, values, religious beliefs, philosophy or other personal values or preferences that are relevant to your instructions. You may also state preferences concerning the location of your care.)
Enter an X to include a section concerning values and preferences about health care. For example, describe values or religious preferences, or the location of treatment. Press [Ctrl+F1] for more information.
Use this space to specify values and preferences.
IAL07
! Optional Limits on Agent's Authority Section (8 of 20)
!. LIMITATIONS ON THE DECISION MAKING AUTHORITY OF MY AGENT:
Enter an X to include a section that allows the Principal to establish limitations on the authority given to the Agent. For example, the Principal may wish to prohibit the Agent from authorizing certain procedures. Press [Ctrl+F1] for more information.
Use this space to specify any limits on the Agent's authority to make decisions on behalf of the Principal.
HMS09
! Inspection and Disclosure Section (9 of 20)
!. INSPECTION AND DISCLOSURE OF INFORMATION RELATING TO MY PHYSICAL OR MENTAL HEALTH. Subject to any limitations in this document, my Agent has the power and authority to:
a. Request, review, and receive any information, verbal or written, regarding my physical or mental health, including, but not limited to, medical and hospital records;
b. Consent to the disclosure of this information to others.
This required section enables the Agent to request, review, and disclose any information regarding the physical or mental condition of the Principal. Press [Ctrl+F1] for more information.
HMS10
! Signing Documents, Waivers and Releases Section (10 of 20)
!. SIGNING DOCUMENTS, WAIVERS, AND RELEASES. Where necessary to implement the health care decisions that my Agent is authorized by this document to make, my Health Care Agent has the power and authority to execute on my behalf any of the following:
a. Documents to authorize my admission to or discharge (even against medical advice) from any hospital, nursing home, residential care or assisted living or similar facility or service;
b. Documents titled or purporting to be "Consent to Permit Treatment" or "Refusal to Permit Treatment"; or
c. Any necessary waiver or release from liability required by a hospital or physician.
This required section gives the Agent the power to sign health care documents (such as admission, discharge, consent, or release forms) on behalf of the Principal. The Agent is NOT responsible for the cost of any medical service provided to the Principal. Press [Ctrl+F1] for more information.
IIL12
! Autopsy, Anatomical Gifts, Disposition of Remains Section (11 of 20)
!. AUTOPSY, ANATOMICAL GIFTS, DISPOSITION OF REMAINS.
! I authorize my Agent, to the extent permitted by law,
! I do not authorize my Agent
to make anatomical gifts of part or all of my body for medical purposes, authorize an autopsy, and direct the disposition of my remains.
This required section states whether or not the Agent has the authority to make anatomical gifts, authorize an autopsy, and decide upon the disposition of the Principal's remains. Press [Ctrl+F1] for more information.
Enter X if the Agent WILL be authorized to make decisions concerning anatomical gifts, autopsies, and the disposition of the Principal's remains, to the extent permitted by law. Press [Ctrl+F1] for more information.
Enter X if the Agent WILL NOT be authorized to make decisions concerning anatomical gifts, autopsies, and the disposition of the Principal's remains, to the extent permitted by law.
HMS12
! Duration Section (12 of 20)
!. DURATION. I understand that this Durable Power of Attorney exists indefinitely from the date I execute this document unless I establish a shorter time or revoke the power of attorney. If I am unable to make health care decisions for myself when this Durable Power of Attorney expires, the authority I have granted my agent continues to exist until the time I become able to make health care decisions for myself.
This power of attorney ends on the following date: !.
This required section states that this document will exist indefinitely unless a specific date is established. Press [Ctrl+F1] for more information.
Enter an X to include a specific date on which the document will cease to be valid. If an expiration date is not specified, this document will remain in force until it is revoked or until the Principal's death. Press [Ctrl+F1] for more information.
Using the format MM/DD/YYYY, enter the date that this document will cease to be valid.
IGN12
! Optional Designation of Alternate Agent Section (13 of 20)
!. DESIGNATION OF ALTERNATE AGENT. If the person designated as my Agent is not available or unable to act, I designate the following persons to serve as my Agent to make health care decisions for me as authorized by this document, who serve in the following order:
FIRST ALTERNATE AGENT
Agent Name: !
Agent Address:Street 1: !
Street 2: !
City: !,
State: !
Zip Code: !
! ___________________________________
___________________________________
___________________________________
___________________________________
Country: !
Phone: Home: ! Work: !
SECOND ALTERNATE AGENT
Agent Name: !
Agent Address:Street 1: !
Street 2: !
City: !,
State: !
Zip Code: !
! ___________________________________
___________________________________
___________________________________
___________________________________
Country: !
Phone: Home: ! Work: !
Enter an X to designate an Alternate Agent. If the original Agent resigns or is unable to perform, an Alternate Agent will assume all responsibilities of the original Agent. Generally, the designation of the Principal's spouse as the Agent is revoked upon divorce. Press [Ctrl+F1] for more information.
Enter the Alternate Agent's name or use the P.I. Manager to select and paste a record.
Enter the Alternate Agent's street address or edit the information as desired.
Enter the Alternate Agent's extended street address or edit the information as desired.
Enter the Alternate Agent's city or edit the information as desired.
Enter the Alternate Agent's state/province or edit the information as desired. When naming an Alternate Agent, consider the availability of the Alternate Agent to confer with health care providers.
Enter the Alternate Agent's zip/postal code or edit the information as desired.
Enter an X to include the Alternate Agent's country. If the Alternate Agent resides in a different country, consider the availability of the Alternate Agent to discuss medical records or information with health care providers.
Enter the country or edit the information as desired.
Enter a phone number at which the Alternate Agent may be reached during non-business hours.
Enter a phone number at which the Alternate Agent may be reached during business hours, if different from the home phone number.
Enter an X to include the name of a second Alternate Agent. You do not have to name a second Alternate Agent.
IID13
! Revocation Section (14 of 20)
!. PRIOR DESIGNATIONS REVOKED. I revoke any prior Durable Power of Attorney for Health Care.
This required revocation section states that any prior Durable Power of Attorney for Health Care made by the Principal is revoked. Press [Ctrl+F1] for more information.
IGN16
! Hold Harmless Section (15 of 20)
!. HOLD HARMLESS. All persons or entities who in good faith endeavor to carry out the terms and provisions of this document shall not be liable to me, my estate, my heirs or assigns for any damages or claims arising because of their action or inaction based on this document, and my estate shall defend and indemnify them.
This is a required section in which the Principal states that the Agent and anyone who relies upon any representation by the Agent shall not be liable to the Principal or any interests involved with the Principal. Press [Ctrl+F1] for more information.
IGN17
! Severability Section (16 of 20)
!. SEVERABILITY. If any provision of this document is held to be invalid, such invalidity shall not affect the other provisions which can be given effect without the invalid provision, and to this end the directions in this document are severable.
This required section prevents the entire document from being invalidated if any provision of the document is declared invalid. Press [Ctrl+F1] for more information.
IGN18
! Statement of Intentions Section (17 of 20)
!. STATEMENT OF INTENTIONS. It is my intent that this document be legally binding and effective. If the law does not recognize this document as legally binding and effective, it is my intent that this document be taken as a formal statement of my desire concerning the method by which any health care decisions should be made on my behalf during any period in which I am unable to make such decisions.
This required section is a statement of the Principal's desire that the document be legally recognized either as a legal document or a formal statement of the Principal's wishes and desires regarding health care decisions. Press [Ctrl+F1] for more information.
HMS18
! Signature Section (18 of 20)
(YOU MUST DATE AND SIGN THIS POWER OF ATTORNEY)
By my signature I do hereby indicate that I understand the purpose and effect of this document.
Signed on _____ day of _______________, 19___.
________________________________________
Signature
Principal Name: !
Principal Address:City: !
County: ! County
State: !
! Country: !
! SSN: !
This section requires the signature of the Principal in the presence of two witnesses or a notary public. If this procedure is not followed, the document may be invalid. Press [Ctrl+F1] for more information.
The program completes the Principal's city. The Principal's name was transferred from a previous section and can be modified only by returning to that section. Use the P.I. Manager to select and paste a record.
Enter the Principal's county or parish or edit the information as desired.
Enter the Principal's state/province or edit the information as desired.
Enter an X to include the Principal's country.
Enter the Principal's country or edit the information as desired.
Enter an X to include the Principal's social security number (SSN). By including the social security number, a health care facility is able to file advance health care directives for future reference. Press [Ctrl+F1] for more information on the Patient Self Determination Act.
Enter the Principal's social security number or edit the information as desired.
HMS19
! Witness/Notary Statement Section (19 of 20)
! [WITNESS BLOCK]
NONE of the following may be used as a witness for a Durable Power of Attorney for Health Care:
1. A health care provider;
2. An employee of a health care provider or facility; or
3. The Attorney-in-Fact.
At least ONE (1) of the witnesses shall NOT be:
1. Related to you by blood, marriage or adoption;
2. An individual who would be entitled to any portion of your estate under any will or codicil existing at the time you sign this document or by operation of law.
WITNESS STATEMENT
I declare under penalty of perjury under the laws of Mississippi that the Principal is personally known to me, that the Principal signed or acknowledged this Durable Power of Attorney in my presence, that the Principal appears to be of sound mind and under no duress, fraud or undue influence, that I am not the person appointed as Attorney-in-Fact by this document, and that I am not a health care provider, nor an employee of a health care provider or facility.
At least one (1) of the witnesses must sign the following statement:
I am not related to the Principal by blood, marriage or adoption, and to the best of my knowledge, I am not entitled to any part of the estate of the Principal upon the death of the Principal under a will now existing or by operation of law.
On this _____ day of _______________, in the year 19___, before me, __________________________________________________ personally appeared !, personally known to me (or proved to me on the basis of satisfactory evidence) to be the person whose name is subscribed to this instrument, and acknowledged that he or she executed it. I declare under the penalty of perjury that the person whose name is subscribed to this instrument appears to be of sound mind and under no duress, fraud or undue influence.
________________________________________
(Notary Seal) Signature of Notary Public
This section requires the signature of two witnesses or a Notary Public. By signing this section, the persons declare that they were present when the Principal signed this document. Note the limits on who may serve as a witness. Press [Ctrl+F1] for more information.
Enter an X if two witnesses will be signing this document. Review the limits on who may be a witness. If the document is not properly witnessed, it may not be enforceable. Press [Ctrl+F1] for more information.
Enter the FIRST witness' name or use the P.I. Manager to select and paste a record. The following information regarding the name and address of the witness may be left blank and be completed when the document is signed.
Enter the witness' street address or edit the information as desired.
Enter the witness' extended street address or edit the information as desired.
Enter the witness' city or edit the information as desired.
Enter the witness' state/province or edit the information as desired.
Enter the witness' zip/postal code or edit the information as desired.
Enter an X to include the witness' country, if outside the United States.
Enter the country or edit the information as desired.
Enter the SECOND witness' name or use the P.I. Manager to select and paste a record. The following information regarding the name and address of the witness may be left blank and be completed when the document is signed.
Enter an X if a Notary Public will be signing the document. The Principal's name was transferred from a prior section and can be modified only by returning to that section. Press [Ctrl+F1] for more information.
DOM01
! Health Care Document Information Section (20 of 20)
You should keep the signed original with your personal papers. Give a copy to your family, your health care provider, and the person you name as your Agent. If you are in a health care facility, a copy of this document should be included in your medical record.
The Health Care Power of Attorney should be reviewed:
- if the Agent or the Alternate Agent is no longer able to serve;
- if the Agent is your spouse and you become separated or divorced;
- if you wish to revise your desires as stated in the document.
It is a good policy to review legal documents every five years to be sure that they are still accurate and appropriate.
This required section provides information regarding the suggested distribution of copies of the Health Care Power of Attorney. Generally, the Agent, family, and health care provider are given a copy. This section will not print as part of the document. Press [Ctrl+F1] for more information.
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