Alaska Stat. § 13.56.180
A supported decision-making agreement must be in substantially the following form:
STATUTORY FORM FOR
SUPPORTED DECISION MAKING AGREEMENT
(1) INTRODUCTION. I, __________________________________, want to have one or more persons I trust help me make decisions, obtain and understand the information I need to make my decisions, and tell other people about my decisions. The people who will help me are my "supporters."
I can name three supporters in this form. If I want to have more than three supporters, I can use a form that is substantially similar to this form to enter into a supported decision-making agreement with the additional supporters.
This is a written agreement between me ("principal") and each of my supporters. I can say in this agreement what kind of help each of my supporters will give me. A SUPPORTER APPOINTED UNDER THIS AGREEMENT DOES NOT MAKE DECISIONS FOR ME.
My supporters may share information with each other (select one of the following):
Yes [ ] No [ ]
(2) SUPPORTERS. These are my supporters:
SUPPORTER NO. 1
Name: __________________________________
Address: _____________________________________
Telephone number:_____________________________________
Electronic mail address: _____
I want this supporter to help me with (mark any of the following you want):
[ ] Making choices about food and clothing
[ ] Making choices about where and with whom I live
[ ] Making choices about my health and health care
[ ] Making choices about how I spend my time
[ ] Making choices about where I work
[ ] Making choices about my support services
[ ] Making choices about how I spend my money and how I save my money
[ ] Making choices about legal matters
[ ] Making choices about (list other areas the supporter will help you with):
_____
_____
I do not want this supporter to help me with:
_____
_____
SUPPORTER NO. 2
Name: __________________________________
Address: _____________________________________
Telephone number:_____________________________________
Electronic mail address: _____
I want this supporter to help me with (mark any of the following you want):
[ ] Making choices about food and clothing
[ ] Making choices about where and with whom I live
[ ] Making choices about my health and health care
[ ] Making choices about how I spend my time
[ ] Making choices about where I work
[ ] Making choices about my support services
[ ] Making choices about how I spend my money and how I save my money
[ ] Making choices about legal matters
[ ] Making choices about (list other areas the supporter will help you with):
_____
_____
I do not want this supporter to help me with:
_____
_____
SUPPORTER NO. 3
Name: __________________________________
Address: _____________________________________
Telephone number:_____
Electronic mail address: _____
I want this supporter to help me with (mark any of the following you want):
[ ] Making choices about food and clothing
[ ] Making choices about where and with whom I live
[ ] Making choices about my health and health care
[ ] Making choices about how I spend my time
[ ] Making choices about where I work
[ ] Making choices about my support services
[ ] Making choices about how I spend my money and how I save my money
[ ] Making choices about legal matters
[ ] Making choices about (list other areas the supporter will help you with):
_____
_____
I do not want this supporter to help me with:
_____
_____
ALTERNATE SUPPORTER. If one of my supporters dies, becomes unable to act as my supporter, refuses to act as my supporter, or terminates the supporter's part of this agreement, I want the following person to become my supporter and help me with the areas the original supporter was helping me with:
Name: __________________________________
Address: _____________________________________
Telephone number:_____________________________________
Electronic mail address: _____
(3) INFORMATION ACCESS FORMS. I am attaching to this agreement (mark yes or no for each choice below):
A form that lets my supporter(s) obtain my health information under the Health Insurance Portability and Accountability Act
Yes [ ] No [ ]
A form that lets my supporter(s) see my educational records under the Family Educational Rights and Privacy Act of 1974
Yes [ ] No [ ]
(4) GUARDIANS AND CONSERVATORS. If I have a guardian or conservator, I must notify the guardian or conservator about this agreement. If this agreement encroaches on the authority of that guardian or conservator, the guardian or conservator must approve this agreement in writing.
[ ] I have a guardian, and I have notified the guardian about this agreement.
[ ] I am attaching a signed statement by my guardian approving my use of this agreement.
[ ] I have a conservator, and I have notified the conservator about this agreement.
[ ] I am attaching a signed statement by my conservator approving my use of this agreement.
(5) NOTICE TO THIRD PARTIES. This is a summary of the rights and obligations of a supporter under AS 13.56, the chapter that authorizes making this agreement. A supporter does not make decisions for the principal, but a supporter may provide a principal with help when making decisions, obtaining information for decisions, communicating decisions, and understanding the options, responsibilities, and consequences of decisions. A supporter may accompany the principal and participate in discussions with other persons. The principal sets out in this agreement the areas in which the supporter may help the principal with decisions.
A third party must recognize a decision or request of the principal that is made or communicated with the assistance of a supporter as the decision or request of the principal (AS 13.56.130) . The principal or supporter may enforce the decision or request in law or equity. A principal may act without the help of the supporter.
(6) DURATION AND TERMINATION OF AGREEMENT. I can end all or part of this agreement at any time by giving notice to my supporter(s). My termination must be signed and notarized or witnessed like this agreement. This agreement starts __________ and will continue until the agreement is terminated by me or my supporter(s).
(7) SIGNATURE OF PRINCIPAL. I know that I do not have to sign this agreement. I am entering into this agreement voluntarily and without coercion or undue influence. I understand the nature and effect of this agreement. I know that I can change this agreement at any time.
Signature: _____________________________________________________
Printed name: __________________________________
Telephone number:_____________________________________
Electronic mail address: _____
Date: __________
(8) SIGNATURES OF SUPPORTERS.
Signature of Supporter No. 1
Signature: _____________________________________________________
Printed name: __________________________________
Date: __________
Signature of Supporter No. 2
Signature: _____________________________________________________
Printed name: __________________________________
Date: __________
Signature of Supporter No. 3
Signature: _____________________________________________________
Printed name: __________________________________
Date: __________
Signature of Alternate Supporter
Signature: _____________________________________________________
Printed name: __________________________________
Date: __________
(9) DECLARATIONS OF SUPPORTERS.
DECLARATION OF SUPPORTER NO.
1. I, __________________________________, am the principal's _____. I am willing to act as the principal's supporter. I acknowledge my duties as a supporter under AS 13.56.
I understand that my job as a supporter is to help the principal make decisions, obtain and understand information for decisions, communicate decisions, and understand the options, responsibilities, and consequences of decisions. My support may include giving the principal information in a way that the principal can understand, discussing pros and cons of decisions, and helping the principal communicate the principal's decisions.
I will act with care, competence, and diligence. I know that I may not make decisions for the principal. I will not exert undue influence on the principal. I will not sign for the principal or provide an electronic signature of the principal to a third party. I will keep the principal's information confidential. I will not use information I receive under this agreement for a purpose other than as authorized by the principal for decision making, unless the principal consents to another use.
Signature: _____________________________________________________
Printed name: __________________________________
Date: __________
DECLARATION OF SUPPORTER NO.
2. I, __________________________________, am the principal's _____. I am willing to act as the principal's supporter. I acknowledge my duties as a supporter under AS 13.56.
I understand that my job as a supporter is to help the principal make decisions, obtain and understand information for decisions, communicate decisions, and understand the options, responsibilities, and consequences of decisions. My support may include giving the principal information in a way that the principal can understand, discussing pros and cons of decisions, and helping the principal communicate the principal's decisions.
I will act with care, competence, and diligence. I know that I may not make decisions for the principal. I will not exert undue influence on the principal. I will not sign for the principal or provide an electronic signature of the principal to a third party. I will keep the principal's information confidential. I will not use information I receive under this agreement for a purpose other than as authorized by the principal for decision making, unless the principal consents to another use.
Signature: _____________________________________________________
Printed name: __________________________________
Date: __________
DECLARATION OF SUPPORTER NO.
3. I, __________________________________, am the principal's _____. I am willing to act as the principal's supporter. I acknowledge my duties as a supporter under AS 13.56.
I understand that my job as a supporter is to help the principal make decisions, obtain and understand information for decisions, communicate decisions, and understand the options, responsibilities, and consequences of decisions. My support may include giving the principal information in a way that the principal can understand, discussing pros and cons of decisions, and helping the principal communicate the principal's decisions.
I will act with care, competence, and diligence. I know that I may not make decisions for the principal. I will not exert undue influence on the principal. I will not sign for the principal or provide an electronic signature of the principal to a third party. I will keep the principal's information confidential. I will not use information I receive under this agreement for a purpose other than as authorized by the principal for decision making, unless the principal consents to another use.
Signature: _____________________________________________________
Printed name: __________________________________
Date: __________
DECLARATION OF ALTERNATE SUPPORTER. I, __________________________________, am the principal's _____. I am willing to act as the principal's supporter in the place of another supporter. I acknowledge the duties as a supporter under AS 13.56.
I understand that my job as a supporter would be to help the principal make decisions, obtain and understand information for decisions, communicate decisions, and understand the options, responsibilities, and consequences of decisions. My support may include giving the principal information in a way that the principal can understand, discussing pros and cons of decisions, and helping the principal communicate the principal's decisions.
I will act with care, competence, and diligence. I know that I may not make decisions for the principal. I will not exert undue influence on the principal. I will not sign for the principal or provide an electronic signature of the principal to a third party. I will keep the principal's information confidential. I will not use information I receive under this agreement for a purpose other than as authorized by the principal for decision making, unless the principal consents to another use.
Signature: _____________________________________________________
Printed name: __________________________________
Date: __________
(10) NOTARIZATION OR WITNESSING. The signatures on this agreement must be either (1) notarized, or (2) witnessed by two witnesses.
NOTARIZATION
State of __________________________________
_____ Judicial District
On this _________ day of _________, in the year _____, before me, __________________________________, appeared __________________________________, and __________________________________, personally known to me to be the persons who executed this agreement, and each acknowledged to me that each executed the agreement as the person's free and voluntary act and deed for the uses and purposes under this agreement.
Witness my hand and official seal the day and year written above.
_____________________________________________________
(Signature of notary public)
(Seal, if any)
_____
(Title and rank)
My commission expires: __________
WITNESSING
If the signatures are not notarized, two adults must witness the signatures of the principal, the supporter(s), and any alternate supporter, and all must sign together in the presence of the witnesses. A witness CANNOT be a supporter named in this agreement. The witnesses CANNOT be employees or agents of the supporter(s) named in this agreement. Unless a person who understands the principal's means of communication is present to assist when the agreement is signed, each witness must understand the means of communication used by the principal.
1. Witness signature: _____________________________________________________
Printed name: __________________________________
Date: __________
2. Witness signature: _____________________________________________________
Printed name: __________________________________
Date: __________
(11) APPROVAL BY GUARDIAN. I am the guardian of __________________________________. I have read and understand the nature and effect of this agreement. I approve the use of this agreement by __________________________________ to obtain support in making decisions.
Signature: _____________________________________________________
Printed name: __________________________________
Date: __________
(12) APPROVAL BY CONSERVATOR. I am the conservator of __________________________________. I have read and understand the nature and effect of this agreement. I approve the use of this agreement by __________________________________ to obtain support in making decisions.
Signature: _____________________________________________________
Printed name: __________________________________
Date: __________
AS 13.56.180