Section 26-1B-4 Form.

A document substantially in the following format may be used to create a supported decision-making agreement that has the meaning and effect prescribed by this chapter. This document IS ___________ / IS NOT _____________ (check one) legally binding. Only a person with the legal right and capacity to contract can make a legally binding agreement. I, ________________________ (Name of Principal), make this supported decision-making agreement to choose supporters to help me make decisions. I am choosing to make this agreement. I may end this agreement at any time. These supporters DO NOT make decisions for me. They give me information, advice, and other support so I can make decisions for myself. DESIGNATION OF SUPPORTERS HEALTH CARE I DO ___________ / DO NOT ______________ (check one) want help with health care. I want the following people to be my supporters and help me with my health care decisions: Name of Supporter: ________________________ Relationship to Principal: ________________________ Repeat as needed for each supporter. I, ___________(Name of Principal), allow these supporters to help me make decisions about my physical and mental health. These people do not make decisions for me - they help me make decisions myself. These supporters can help me in these ways: ________________________ These supporters MAY NOT do these things: ________________________ FINANCIAL DECISION-MAKING I DO ___________ / DO NOT ______________ (check one) want help with my financial decisions. I want the following people to be my supporters and help me with my financial decisions: Name of Supporter: ________________________ Relationship to Principal: ________________________ Repeat as needed for each supporter. I, ___________(Name of Principal), allow these supporters to help me make decisions about my finances. These people do not make decisions for me - they help me make decisions myself. These supporters can help me in these ways: ________________________ These supporters MAY NOT do these things: ________________________ WHERE I LIVE AND COMMUNITY LIVING I DO ___________ / DO NOT ______________ (check one) want help with decisions about where I live and community living. I want the following people to be my supporters and help me with decisions about where I live: Name of Supporter: ________________________ Relationship to Principal: ________________________ Repeat as needed for each supporter. I, ___________(Name of Principal), allow these supporters to help me make decisions about where I live and community living. These people do not make decisions for me - they help me make decisions myself. These supporters can help me in these ways: ________________________ These supporters MAY NOT do these things: ________________________ EDUCATION I DO ___________ / DO NOT ______________ (check one) want help with decisions about my education. I want the following people to be my supporters and help me with decisions about my education: Name of Supporter: ________________________ Relationship to Principal: ________________________ Repeat as needed for each supporter. I, ___________(Name of Principal), allow these supporters to help me make decisions about my education. These people do not make decisions for me - they help me make decisions myself. These supporters can help me in these ways: ________________________ These supporters MAY NOT do these things: ________________________ EMPLOYMENT I DO ___________ / DO NOT ______________ (check one) want help with decisions about my employment. I want the following people to be my supporters and help me with decisions about my employment: Name of Supporter: ________________________ Relationship to Principal: ________________________ Repeat as needed for each supporter. I, ___________(Name of Principal), allow these supporters to help me make decisions about my employment. These people do not make decisions for me - they help me make decisions myself. These supporters can help me in these ways: ________________________ These supporters MAY NOT do these things: ________________________ OTHER DECISIONS I DO ___________ / DO NOT ______________ (check one) want help with other decisions. I want the following people to be my supporters and help me with other decisions: Name of Supporter: ________________________ Relationship to Principal: ________________________ Repeat as needed for each supporter. I, ___________(Name of Principal), allow these supporters to help me make other decisions. These people do not make decisions for me - they help me make decisions myself. These supporters can help me in these ways: ________________________ These supporters MAY NOT do these things: ________________________ SIGNATURE AND ACKNOWLEDGMENT I agree to be a supporter under this agreement. (Signature of Supporter): ________________________ Signature Date: ________________________ Supporter Name Printed: ________________________ Supporter Address: ________________________ Supporter Telephone Number: ________________________ Supporter E-mail Address: ________________________ Repeat as needed for each supporter listed in the supported decision-making agreement. (Signature of Principal): ________________________ Your Signature Date: ________________________ Your Name Printed: ________________________ Your Address: ________________________ Your Telephone Number: ________________________ State of: ________________________ [County] of ________________________ I, ____________, a Notary Public, in and for the County in this State, hereby certify that ____________, whose name is signed to the foregoing document, and who is known to me, acknowledged before me on this day that, being informed of the contents of the document, he or she executed the same voluntarily on the day the same bears date. Given under my hand this the ____________ day of ____________, 2___. ________________________ (Seal, if any) Signature of Notary My commission expires: ________________________ [This document prepared by: _______________________]