To my family:

The time may come when I can no longer make the best decisions for the safety of others and
myself. Therefore, in order to help my family make necessary decisions, this statement is an
expression of my wishes and directions while I am still able to make these decisions.

I have discussed with my family my desire to drive as long as it is safe for me to do so.

When it is not reasonable for me to drive, I desire ________________ (person’s name) to tell
me I can no longer drive.

I trust my family will take the necessary steps to prohibit my driving in order to ensure my safety
and the safety of others while protecting my dignity. Signed

_____________________________________________ Date ______________

Copies of this request have been shared with:

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