This required section includes the Nondonor's name and address. The Nondonor is the individual who is documenting the desire NOT to be an organ donor after the Nondonor's death. Press [Ctrl+F1] for more information.
This optional section should be completed by anyone who has previously completed an organ donation form and now desires NOT to be an organ donor. This section revokes all previous donations. Press [Ctrl+F1] for more information.
This required section provides that the inclusion of an invalid request or instruction does not invalidate the other provisions of the document. Press [Ctrl+F1] for more information.
This required section provides for the appropriate signatures on the Refusal to Donate Form. Press [Ctrl+F1] for more information.
Times New Roman
Arial
Refusal to Donate Organs Form
REFUSE
The Refusal to Donate Organs Form allows a person to state his/her intent that such person's body organs and tissues should not be removed and donated at such person's death.
Enter the Nondonor's state. The Nondonor is the person expressing the desire NOT to be an organ donor after death. The Nondonor's selected state will control some of the language in the document. If the Nondonor is unsure which state to enter, an attorney should be consulted.
Enter the name of the Nondonor or edit the information as desired. Use the P.I. Manager to select and paste a record.
REF01
! Refusal To Donate Section (1 of 5)
REFUSAL TO DONATE FORM
[THIS DOCUMENT MAY BE USED TO:
* DOCUMENT THE REFUSAL TO MAKE AN ORGAN DONATION
* REVOKE A PRIOR ORGAN DONATION AND DOCUMENT THE REFUSAL
TO MAKE AN ORGAN DONATION]
[This document has some state specific material. Enter the state where the Nondonor currently resides: !.]
I, !, of
!, ! !,
refuse to donate any of my organs, tissues, or parts to be used for any purpose upon my death.
Enter the Nondonor's state. The Nondonor is the person expressing the desire NOT to be an organ donor after death. The Nondonor's selected state will control some of the language in the document. If the Nondonor is unsure which state to enter, an attorney should be consulted.
Enter the name of the Nondonor or edit the information as desired. Use the P.I. Manager to select and paste a record.
Enter the Nondonor's street address or edit the information as desired.
Enter the Nondonor's extended street address or edit the information as desired.
Enter the Nondonor's city or edit the information as desired.
Enter the Nondonor's zip code or edit the information as desired.
REF02
! Optional Revocation of Prior Donation Section (2 of 5)
[WARNING: A NONDONOR MAY NEED TO DO MORE THAN COMPLETE THIS OPTIONAL SECTION TO ASSURE A PREVIOUSLY COMPLETED ORGAN DONATION FORM IS NOT HONORED. FOR EXAMPLE IF AN ORIGINAL DONOR FORM WAS DELIVERED TO AN ORGANIZATION, THAT ORGANIZATION SHOULD BE NOTIFIED OF THE FORM'S REVOCATION AND SHOULD BE GIVEN A COPY OF THIS "REFUSAL TO DONATE FORM." ADDITIONAL INFORMATION IS AVAILABLE IN DOCUMENT INFORMATION.]
I revoke any previous document or writing where I donated my organs, tissues, or parts to take effect on my death.
Enter an X to include this optional section that should be completed by any Nondonor who has previously donated organs and now desires NOT to be an organ donor. This section revokes all previous donations. Press [Ctrl+F1] for more information.
REF03
! Severability Section (3 of 5)
If any provision in 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.
REF04
! Signature Section (4 of 5)
! THE NONDONOR IS ! (!) YEARS OLD OR OLDER AND ABLE TO SIGN THE FORM
! THE NONDONOR IS ! (!) YEARS OLD OR OLDER AND PHYSICALLY UNABLE TO SIGN THE FORM
! THE NONDONOR IS UNDER THE AGE OF ! (!)
! [Ohio and Wyoming] THE NONDONOR IS UNDER THE AGE OF EIGHTEEN (18) AND LIVES IN OHIO OR WYOMING
! [Nevada only] THE NONDONOR IS TWELVE (12) YEARS OLD OR OLDER BUT UNDER THE AGE OF EIGHTEEN (18) AND LIVES IN NEVADA
! [Nevada only] THE NONDONOR IS UNDER THE AGE OF TWELVE (12) YEARS OLD AND LIVES IN NEVADA
Enter an X if the Nondonor meets the age requirement and is able to sign the form. The program supplies the appropriate age for the state in which the Nondonor resides. While minors in some states, may execute a document without parental consent, the third option is recommended for most minors.
Enter an X if the Nondonor meets the age requirement but is physically unable to sign the form. The program supplies the appropriate age for the state in which the Nondonor resides.
Enter an X if the Nondonor is under the age provided. This option provides for parental or guardian consent. The program supplies the appropriate age for the state in which the Nondonor resides. Minors who are completing this document should read Document Information regarding the effectiveness of this form when signed by a minor.
Enter an X if the Nondonor is under the age of 18 and lives in Ohio or Wyoming. This option provides for parental or guardian consent. Minors who are completing this document should read Document Information regarding the effectiveness of this form when signed by a minor.
Enter an X if the Nondonor is 12 years old or older but under the age of 18 and lives in Nevada. This option provides for parental or guardian consent. Minors who are completing this document should read Document Information regarding the effectiveness of this form when signed by a minor.
Enter an X if the Nondonor is under the age of 12 and lives in Nevada. This option provides for parental or guardian consent. Minors who are completing this document should read Document Information regarding the effectiveness of this form when signed by a minor.
I witnessed that this document was signed in my presence by the Nondonor. I am signing in the presence of and at the direction of the Nondonor and in the presence of the other witness:
! [Illinois] and certify that the Nondonor was of sound mind and memory and free of any undue influence and knew the objects of his bounty and affection.
! I witnessed that this document was signed in my presence by the Nondonor. I am signing in the presence of and at the direction of the Nondonor and in the presence of the other witness:
! I witnessed that this document was signed in my presence by the Nondonor and certify that the Nondonor was of sound mind and memory and free of any undue influence and knew the objects of his bounty and affection. I am signing in the presence of and at the direction of the Nondonor and in the presence of the other witness:
[STATE LAWS GENERALLY DO NOT REQUIRE THAT AN INDIVIDUAL'S REFUSAL TO DONATE OR OTHER EXPRESSIONS OF THE DESIRE NOT TO BE AN ORGAN DONOR BE WITNESSED. THE MAJORITY OF STATES DO NOT HAVE EXPLICIT REQUIREMENTS CONCERNING THE REFUSAL TO DONATE. SINCE MOST STATES REQUIRE WITNESSES FOR AN ORGAN DONATION, NONDONORS ARE ALSO ENCOURAGED TO HAVE TWO INDIVIDUALS WITNESS THE NONDONOR'S SIGNATURE AND SIGN THE FORM AS WITNESSES.]
Using the format MM/DD/YYYY, enter the Nondonor's date of birth or edit the information as desired. Nondonors should be "competent" to execute a valid refusal. Press [Ctrl+F1] for more information.
The program completes this checkbox if the Nondonor resides in Illinois. Illinois requires that witnesses certify to certain information about an organ donor's state of mind. The same information is recommended in regards to a Nondonor.
Enter the name of the FIRST witness or use the P.I. Manager to select and paste a record. The name of the witness may be left blank and completed when the document is signed. It is recommended that two individuals witness the Nondonor's signature and sign as witnesses.
Enter the name of the SECOND witness or use the P.I. Manager to select and paste a record. The name of the witness may be left blank and completed when the document is signed. It is recommended that two individuals witness the Nondonor's signature and sign as witnesses.
Illinois
Illinois
Illinois
REF06
! Continuation of Signature Section (5 of 5)
I, !, am signing this document at the direction of and in the presence of the Nondonor, !, who is physically unable to sign and in the presence of two additional witnesses who sign below.
I witnessed that this document was signed in my presence by ! at the direction of and in the presence of the Nondonor who was physically unable to sign. I am signing in the presence of and at the direction of the Nondonor and in the presence of the other witness:
! [Illinois] and certify that the Nondonor was of sound mind and memory and free of any undue influence and knew the objects of his bounty and affection.
! I witnessed that this document was signed in my presence by ! at the direction of and in the presence of the Nondonor who was physically unable to sign. I am signing in the presence of and at the direction of the Nondonor and in the presence of the other witness:
! I witnessed that this document was signed in my presence by ! at the direction of and in the presence of the Nondonor who was physically unable to sign and certify that the Nondonor was of sound mind and memory and free of any undue influence and knew the objects of his bounty and affection. I am signing in the presence of and at the direction of the Nondonor and in the presence of the other witness:
[STATES THAT REFER TO A REFUSAL TO DONATE DOCUMENT REQUIRE TWO WITNESSES WHEN ANOTHER INDIVIDUAL SIGNS ON BEHALF OF A NONDONOR. HOWEVER, THE MAJORITY OF STATES DO NOT HAVE EXPLICIT REQUIREMENTS CONCERNING THE REFUSAL TO DONATE. IT IS STRONGLY RECOMMENDED THAT NONDONORS IN ALL STATES HAVE TWO INDIVIDUALS WITNESS THAT A THIRD INDIVIDUAL HAS SIGNED ON BEHALF OF THE NONDONOR AND SIGN AS WITNESSES.]
Enter the name of the person who will sign on behalf of the Nondonor or use the P.I. Manager to select and paste a record. A representative may sign the form on behalf of an adult Nondonor who is physically unable to sign. The name of the representative may be left blank and completed when the document is signed.
Using the format MM/DD/YYYY, enter the Nondonor's date of birth or edit the information as desired. Nondonors should be "competent" to execute a valid refusal. Press [Ctrl+F1] for more information.
The program completes this checkbox if the Nondonor resides in Illinois. Illinois requires that witnesses certify to certain information about an organ donor's state of mind. The same information is recommended in regards to a Nondonor.
Enter the name of the FIRST witness or use the P.I. Manager to select and paste a record. The name of the witness may be left blank and completed when the document is signed. It is strongly encouraged that two individuals witness that a third individual signed on behalf of the Nondonor and sign as witnesses.
Enter the name of the SECOND witness or use the P.I. Manager to select and paste a record. The name of the witness may be left blank and completed when the document is signed. It is strongly encouraged that two individuals witness that a third individual signed on behalf of the Nondonor and sign as witnesses.
Illinois
Illinois
Illinois
REF07
! Continuation of Signature Section (5 of 5)
[MOST STATES DO NOT ADDRESS WHETHER A REFUSAL TO DONATE DOCUMENT COMPLETED BY A MINOR IS VALID. EVEN STATES THAT ALLOW A MINOR TO MAKE AN ORGAN DONATION WITH PARENTAL CONSENT GENERALLY DO NOT EXPLICITLY ALLOW A MINOR TO REFUSE TO DONATE WITH PARENTAL CONSENT. IT IS QUITE POSSIBLE THAT A REFUSAL TO DONATE FORM COMPLETED BY A MINOR MAY NOT BE A VALID DOCUMENT IN MOST STATES. HOWEVER, IF MINORS DO NOT WANT TO DONATE ORGANS, THEY ARE ENCOURAGED TO COMPLETE A "REFUSAL TO DONATE
FORM" AS IT IS AN INDICATION OF THEIR WISHES. IF A MINOR COMPLETES A FORM, IT IS RECOMMENDED THAT A MINOR OBTAIN THE SIGNATURE OF AT LEAST ONE PARENT OR GUARDIAN AND TWO WITNESSES IF POSSIBLE. WHILE SOME STATES, SUCH AS MAINE, ALLOW INDIVIDUALS 16 YEARS OLD OR OLDER TO COMPLETE DONOR FORMS WITHOUT CONSENT, IT IS RECOMMENDED THAT MINORS IN ALL STATES HAVE A PARENT OR GUARDIAN SIGN THE REFUSAL FORM TO INCREASE THE LIKELIHOOD THAT THE FORM WILL BE HONORED IN OTHER STATES.]
!, !
! and !,
as the
! Parent(s)
! Guardian(s)
of the Nondonor, !, consent to the Nondonor's refusal to donate organs, tissues or parts as directed in this document and sign this document in the presence of the Nondonor and two additional witnesses who sign below.
I witnessed that this document was signed in my presence by the Nondonor and the Nondonor's !. I am signing in the presence of and at the direction of the Nondonor and in the presence of the other witness:
! [Illinois] and certify that the Nondonor was of sound mind and memory and free of any undue influence and knew the objects of his bounty and affection.
! I witnessed that this document was signed in my presence by the Nondonor and the Nondonor's !. I am signing in the presence of and at the direction of the Nondonor and in the presence of the other witness:
! I witnessed that this document was signed in my presence by the Nondonor and the Nondonor's ! and certify that the Nondonor was of sound mind and memory and free of any undue influence and knew the objects of his bounty and affection. I am signing in the presence of and at the direction of the Nondonor and in the presence of the other witness:
Enter the name of the parent or guardian who consents to the minor's refusal to donate and will sign the form or use the P.I. Manager to select and paste a record. The name of the parent or guardian may be left blank and completed when the document is signed.
Enter an X if a second parent or guardian will be consenting to a minor's refusal to donate.
Enter the name of the second parent or guardian who consents to the minor's refusal to donate and will sign the form or use the P.I. Manager to select and paste a record. The name of the parent or guardian may be left blank and completed when the document is signed.
Enter an X if the minor's parent(s) will be consenting to the minor's refusal to donate. Some states prefer that parents, instead of guardians, sign the form if possible.
Enter an X if the minor's guardian(s) will be consenting to the minor's refusal to donate.
The program completes the checkbox if a second parent or guardian will be signing the form. You may modify the information only by returning to that section.
Using the format MM/DD/YYYY, enter the Nondonor's date of birth or edit the information as desired.
The program completes this field by transferring the information from a previous section. You may modify the information only by returning to that section.
The program completes this checkbox if the Nondonor resides in Illinois. Illinois requires that witnesses certify to certain information about an organ donor's state of mind. The same information is recommended in regards to a Nondonor.
Enter the name of the FIRST witness or use the P.I. Manager to select and paste a record. The name of the witness may be left blank and completed when the document is signed. It is recommended that two individuals witness the Nondonor and parent or guardian signatures.
Enter the name of the SECOND witness or use the P.I. Manager to select and paste a record. The name of the witness may be left blank and completed when the document is signed. It is recommended that two individuals witness the Nondonor and parent or guardian signatures.
parents
parent
guardians
guardian
Illinois
Illinois
Illinois
REF08
! Continuation of Signature Section (5 of 5)
[MOST STATES DO NOT ADDRESS WHETHER A REFUSAL TO DONATE DOCUMENT COMPLETED BY A MINOR IS VALID. EVEN STATES THAT ALLOW A MINOR TO MAKE AN ORGAN DONATION WITH PARENTAL CONSENT GENERALLY DO NOT EXPLICITLY ALLOW A MINOR TO REFUSE TO DONATE WITH PARENTAL CONSENT. IT IS QUITE POSSIBLE THAT A REFUSAL TO DONATE FORM COMPLETED BY A MINOR MAY NOT BE A VALID DOCUMENT IN MOST STATES. HOWEVER, IF MINORS DO NOT WANT TO DONATE ORGANS, THEY ARE ENCOURAGED TO COMPLETE A "REFUSAL TO DONATE
FORM" AS IT IS AN INDICATION OF THEIR WISHES. IF A MINOR COMPLETES A FORM, IT IS RECOMMENDED THAT A MINOR OBTAIN THE CONSENT OF AT LEAST ONE PARENT OR GUARDIAN AND THE SIGNATURE OF ONE ADDITIONAL WITNESSES IF POSSIBLE.]
[Nevada, Ohio and Wyoming]
!, !
! and !,
as the
! Parent(s)
! Guardian(s)
of the Nondonor, !, consent to the Nondonor's refusal to donate organs, tissues, or parts as directed in this document.
I witnessed that this document was signed in my presence by the Nondonor. I am signing in the presence of and at the direction of the Nondonor and in the presence of the other witness.
WARNING: One of the witnesses should be a parent or guardian who also consented to the refusal to donate.
Enter the name of the parent or guardian who consents to the minor's refusal to donate and will sign the form or use the P.I. Manager to select and paste a record. The name of the parent or guardian may be left blank and completed when the document is signed.
Enter an X if two parents or guardians will be consenting to a minor's refusal to donate.
Enter the name of the second parent or guardian who consents to the minor's refusal to donate and will sign the form or use the P.I. Manager to select and paste a record. The name of the parent or guardian may be left blank and completed when the document is signed.
Enter an X if the minor's parent(s) will be consenting to the minor's refusal to donate. Some states prefer that parents, instead of guardians, sign the form if possible.
Enter an X if the minor's guardian(s) will be consenting to the minor's refusal to donate.
The program completes the checkbox if a second parent or guardian will be signing the form. You may modify the information only by returning to that section.
Using the format MM/DD/YYYY, enter the Nondonor's date of birth or edit the information as desired.
Enter the name of the FIRST witness or use the P.I. Manager to select and paste a record. The name of the witness may be left blank and completed when the document is signed. At least one of the witnesses should be a parent or guardian who also consents to the refusal to donate.
Enter the name of the SECOND witness or use the P.I. Manager to select and paste a record. The name of the witness may be left blank and completed when the document is signed. At least one of the witnesses should be a parent or guardian who also consents to the refusal to donate.
REF09
! Continuation of Signature Section (5 of 5)
[MOST STATES DO NOT ADDRESS WHETHER A REFUSAL TO DONATE DOCUMENT COMPLETED BY A MINOR IS VALID. EVEN STATES THAT ALLOW A MINOR TO MAKE AN ORGAN DONATION WITH PARENTAL CONSENT GENERALLY DO NOT EXPLICITLY ALLOW A MINOR TO REFUSE TO DONATE WITH PARENTAL CONSENT. IT IS QUITE POSSIBLE THAT A REFUSAL TO DONATE FORM COMPLETED BY A MINOR MAY NOT BE A VALID DOCUMENT IN MOST STATES. HOWEVER, IF MINORS DO NOT WANT TO DONATE ORGANS, THEY ARE ENCOURAGED TO COMPLETE A "REFUSAL TO DONATE
FORM" AS IT IS AN INDICATION OF THEIR WISHES. IF A MINOR COMPLETES A FORM, IT IS RECOMMENDED THAT A MINOR OBTAIN THE CONSENT OF AT LEAST ONE PARENT OR GUARDIAN WHO SIGNS ON BEHALF OF THE MINOR AND THE SIGNATURE OF TWO ADDITIONAL WITNESSES IF POSSIBLE.]
[Nevada Nondonors under the age of 12]
!, !
! and !,
as the
! Parent(s)
! Guardian(s)
of the Nondonor, !, consent to the Nondonor's refusal to donate organs, tissues, or parts as directed in this document and hereby sign this document on behalf of the Nondonor and in the presence of the Nondonor and two additional witnesses who sign below.
I witnessed that this document was signed in my presence by the Nondonor's !. I am signing in the presence of and at the direction of the Nondonor and the Nondonor's ! and in the presence of the other witness:
Enter the name of the parent or guardian who consents to the minor's refusal to donate and will sign the form on behalf of the minor or use the P.I. Manager to select and paste a record. The name of the parent or guardian may be left blank and completed when the document is signed.
Enter an X if two parents or guardians will be consenting to a minor's refusal to donate.
Enter the name of the second parent or guardian who consents to the minor's refusal to donate and will sign the form on behalf of the minor or use the P.I. to select and paste a record. The name of the parent or guardian may be left blank and completed when the document is signed.
Enter an X if the minor's parent(s) will be consenting to the minor's refusal to donate. Some states prefer that parents, instead of guardians, sign the form if possible.
Enter an X if the minor's guardian(s) will be consenting to the minor's refusal to donate.
The program completes the checkbox if a second parent or guardian will be signing the form. You may modify the information only by returning to that section.
Using the format MM/DD/YYYY, enter the Nondonor's date of birth or edit the information as desired.
The program completes this field by transferring the information from a previous section. You may modify the information only by returning to that section.
Enter the name of the FIRST witness or use the P.I. Manager to select and paste a record. The name of the witness may be left blank and completed when the document is signed.
Enter the name of the SECOND witness or use the P.I. Manager to select and paste a record. The name of the witness may be left blank and completed when the document is signed.
(.txt)