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WITNESSES
On this day, ____________________________date of ________________________________________, the
undersigned declared to us that this instrument was his/her Will and requested us to act as witnesses to it.
He/She thereupon signed this Will in our presence, all of us being present at the same time. We now, at his/
her request, in his/her presence, and in the presence of each other, subscribe our names as witness and
declare that we understand this to be his/her Last Will, and that, to the best of our knowledge the testator is
of the age of majority, or is otherwise legally empowered to make a Will, and under no constraint or
undue influence.
Witness 1.
________________________________________________________________________________________________
Name and Signature
Witness 2.
_________________________________________
_______________________________________________________
Name and Signature
HEALTH CARE PROXY AND LIVING WILL
If the time comes when I am incapacitated and can no longer actively take part in decisions for my own life and am
unable to direct my physician as to my own medical care, I wish this statement to stand as a testament of my wishes.
I,
________________________________________________________________________________________
hereby appoint the following individual as my health care agent.
Name:
____________________________________Phone#________________________________
Address:
________________________________________________________________________________________________
This health care proxy shall take effect if and when I become unable to make my own health care decisions. In respect
of each decision made for me by my agent, it is my wish and direction that my agent be guided solely by Islamic
Shariah as to what my own decision would have been in the same circumstances. Without limiting the unrestricted
scope of my agent’s authority hereunder, I expressly authorize my agent to direct that no treatment be conducted or
withheld from me if to do so is against the teachings of Islam, to the best of understanding of my agent. I direct that
medication be judiciously administered to me to alleviate pain. I do not intend any direct taking of my life. I also
direct that “life support systems” may be used in a judicious manner and its use discontinued, just like any other
medicine, if it becomes reasonably apparent that it has no curative value. The “life support systems” include but are
not limited to artificial respiration, cardiopulmonary resuscitation, artificial means of providing nutrition and
hydration, and any pharmaceutical drugs. I direct that my family, all physicians, hospitals and other health care
providers and any court or judge honor the decision of my agent/alternate agent. This request is made, after careful
reflection, while I am of sound mind.
Name:__________________________________________Signature:___________________________________________________
Witness 1.
__________________________________________________________________________________________________
Name and Signature
Witness 2.
__________________________________________________________________________________________________
Name and Signature
***OPTIONAL***
Subscr ibed and sworn to before me this_______________day of ___________, ___________________
Notary Publ ic ___________________________________________________________Signature & Seal
In Case of Emergency Contact: (Include Mosques and all phone numbers)
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
We hope this will benefit you and your family.
For a will to be legal in most states, you have to be at least 18
years old and of sound mind. The will must be signed by you and witnessed by two people who won’t receive
anything from your estate.
However, please consult with an Islamic Scholar and/ or an attorney first. As
always, please feel free to pass or share this information on to your friends and other Muslims. Pray for the
people at The Islamic Bulletin who prepared this sample Will for you. Jazakum Allahu Khairan (May Allah
Reward You). If you want a copy in Arabic, French, Spanish, or need more copies are needed please go to:
www.islamicbulletin.org
and click on enter here and then Islamic Last Will. For a list of mosques click
mosques under enter here. You can print the whole mosques in a PDF format. Rev. 2008
For More Information Please Contact:
The Islamic Bulletin ,
P.O. Box 410186, San Francisco, CA 94141-0186
Web:
www.islamicbulletin.org E-Mail: info@islamicbulletin.org
THIS INFORMATION IS REQUIRED FOR THE DEATH CERTIFICATE:
Full Name ___________________________________________________________________________
Date Of Birth _______________________Place Of Birth ______________________________________
Social Security Number ___________________________________Race _________________________
Street Address And Zip _________________________________________________________________
City/Town Of Residence_______________ County Of Residence_______________________________
Full Name Of Father __________________________________________________________________
First And Maiden Name Of Mother ______________________________________________________
Highest Level Of Education In Years
Elementary/Secondary (0-12) _____________ College (1-4 Or 5+) _____________________________
Marital Status (Circle): Never Married Married Widowed Divorced
If Married Or Widowed, Name Of Spouse _______________________________________________
Usual Or Last Occupation ___________ Kind Of Business Or Industry__________________________
Name Of Attending Physician _________________________________________________________
Next of Kin and Contact info:
_____________________________________________________________
THE NET VALUE OF YOUR ESTATE
I. ASSETS
(Add up what you own and where located)
A. Personal Property
:
1.
Cash
___________________________________Located:_________________________________________
Cash
___________________________________Located:__________________________________________
2.
Savings:
________________________________________Bank___________________________________
Savings:
__________________________________________Bank___________________________________
3.
Checking:
___________________________________Bank______________________________________
4.
Other :
_________________________________________________________________________________
5. Interest in Prof i t Shar ing, Stock, Par tnership, etc.__________________________________________________
6. Automobi les , Jewel ry, Household & Clothing____________________________________________________
7.
Miscel laneous____________________________________________________________________________
B. Real Estate
(describe for each property you own)
Value______________________________________________________Located______________________________________
Value______________________________________________________Located_____________________________________
Total Value of al l the above assets: ______________________________________________________________
II. LABILITIES
(add what you owe)
1. Money Owed to________________________________________$_________________________________
Address and Phone: _________________________________________________________________________
2. Money Owed to________________________________________$_________________________________
Address and Phone: _________________________________________________________________________
3. Money Owed to_______________________________________$__________________________________
Address and Phone: _________________________________________________________________________
4.
Mor tgage______________________________________________________________________________
5. Personal debts: ( loans , car , etc. )______________________________________________________________
Total
Amount
owed
:________________________________________________________________________
Safe Deposi t Box_______________________ located at __________________________________________
Passpor t # &Type __________________________ Impor tant Passwords #: ___________________________
This document, comprising ________pages, is made in _______ copies. The original is with me,
One copy is deposi ted wi th ________________________________________________ Name and Phone #
and one copy wi th
_______________________________________________________
Name and Phone #