Wis. Stat. § 52.20
SUPPORTED DECISION-MAKING AGREEMENT APPOINTMENT OF SUPPORTER
I, .... (insert name), make this agreement voluntarily and of my own free will.
I agree and designate that
Name of supporter ....
Address of supporter ....
E-mail address of supporter ....
Phone number(s) of supporter ....
is my supporter. For the following everyday life decisions, if I have checked "Yes," my supporter may help me with that type of decision, but if I have checked "No," my supporter may not help me with that type of decision:
Obtaining food, clothing, and shelter - Yes.... No....
Taking care of my physical health - Yes.... No....
Managing my financial affairs - Yes.... No....
Taking care of my mental health - Yes.... No....
Applying for public benefits - Yes.... No....
Assistance with seeking vocational rehabilitation services and other vocational supports - Yes.... No....
The following are other decisions I have specifically identified that I would like assistance with ....
If I have not checked either "Yes" or "No" or specifically identified and listed a decision immediately above, my supporter may not help me with that type of decision.
My supporter is not allowed to make decisions for me. To help me with my decisions, my supporter may do any of the following, if I have checked "Yes":
Medical - Yes.... No....
Psychological - Yes.... No....
Financial - Yes.... No....
Education - Yes.... No....
Treatment - Yes.... No....
Other - Yes.... No.... (If "Yes," specify the other type(s) of information with which the supporter may assist ....)
EFFECTIVE DATE OF SUPPORTED DECISION-MAKING AGREEMENT
This supported decision-making agreement is effective immediately and will continue until .... (insert date), or until the agreement is terminated by my supporter or me or by operation of law.
(print) Name of person designating a supporter ....
Signature ....
Date ....
CONSENT OF SUPPORTER
I know .... (name of person) personally or I have received proof of his or her identity and I believe him or her to be at least 18 years of age and entering this agreement knowingly and voluntarily. I am at least 18 years of age.
I, .... (name of supporter), consent to act as a supporter under this agreement.
Supporter:
(print) Name ....
Address ....
E-mail address ....
Phone number(s) ....
Signature ....
Date ....
STATEMENT AND SIGNATURE OF WITNESSES OR SIGNATURE OF NOTARY
(This agreement must be signed either by 2 witnesses who are at least 18 years of age or by a notary public.)
OPTION I: WITNESSES
I know .... (name of person) personally or I have received proof of his or her identity and I believe him or her to be at least 18 years of age and entering this agreement knowingly and voluntarily. I am at least 18 years of age.
Witness No. 1:
(print) Name ....
Address ....
Phone number(s) ....
Signature ....
Date ....
Witness No. 2:
(print) Name ....
Address ....
Phone number(s) ....
Signature ....
Date ....
OPTION II: NOTARY PUBLIC
State of ....
County of ....
This document was acknowledged before me on .... (date), by (name of adult with a functional impairment) and ..... (name of supporter).
Signature of notary ....
(Seal, if any, of notary)
Printed name ....
My commission expires: ....
Wis. Stat. § 52.20