N.H. Rev. Stat. § 464-D:16
A supported decision-making agreement may be in any form not inconsistent with the following form and the other requirements of this chapter. Use of the following form is presumed to meet statutory provisions.
SUPPORTED DECISION-MAKING AGREEMENT
This agreement must be communicated to all parties to the agreement in the presence of either a notary or 2 witnesses. The form of communication must be appropriate to the needs and preferences of the person with a disability. Reading the agreement out loud or using a sign language interpreter may be necessary.
My name is ______________________________.
I want to have people I trust help me make decisions. The people who will help me are called supporters. My supporters are not allowed to make the decisions for me. I will make my own choices, with their support. I am called the principal.
This agreement can be changed at any time. I can change it by crossing out words and writing my initials next to the change. I can also end this agreement at any time by . Signature of Principal
I am making this supportive decision-making agreement because I want people to help me make choices. I know that I do not have to make this agreement. I know that I can change this agreement at any time.
My printed name: _____________________________________________.
My address: _____________________________________________
My phone number: _____________________________________________.
My email address: _____________________________________________.
Today's date: _____________________________________________
Supporters
Supporter #1
I agree that ______________________________(name) will be my supporter. Their contact information is:.
Address: _____________________________________________.
Phone Number: _____________________________________________.
E-mail Address: _____________________________________________
My supporter may help me with making everyday life decisions relating to the following:.
Obtaining food, clothing, and shelter: Yes __________ No __________
Taking care of my physical health: Yes __________ No __________
Taking care of my mental health: Yes __________ No __________
Managing my financial affairs: Yes __________ No __________
Applying for and managing public benefits: Yes __________ No __________
My education: Yes __________ No __________
Applying for and managing employment: Yes __________ No __________
The following are other decisions that I have specifically identified that I would like assistance with:
__________________________________________________.
Supporter #2.
I do not have to have more than one supporter. I choose to have ______________________________ (name) also be my supporter. Their contact information is:.
Address: _____________________________________________.
Phone Number: _____________________________________________.
E-mail Address: _____________________________________________
is my supporter. My supporter may help me with making everyday life decisions relating to the following:
Obtaining food, clothing, and shelter: Yes ____ No ____
Taking care of my physical health: Yes ____ No ____
Taking care of my mental health: Yes ____ No ____
Managing my financial affairs: Yes ____ No ____
Applying for and managing public benefits: Yes ____ No ____
My education: Yes ____ No ____
Applying for and managing employment: Yes ____ No ____
The following are other decisions that I have specifically identified that I would like assistance with:
__________________________________________________.
To help me with my decisions, my supporter(s) may do the following things (check all that apply):
( ) Help me access, collect, or obtain information that is relevant to a decision, including medical, psychological, educational, or treatment records;.
( ) Help me gather and complete appropriate authorizations and releases;.
( ) Help me understand my options so I can make an informed decision; and.
( ) Help me communicate my decision to appropriate persons.
Monitor for Financial Matters
If I want someone to help me make choices about money, I may also choose someone to make sure my supporters are being honest and using good judgment in helping me with my money. This person is called a monitor. A monitor cannot also be a supporter.
I agree that ______________________________ (name) will be my monitor. Their contact information is:
Address: __________________________________________________
Phone Number: __________________________________________________.
E-mail Address: __________________________________________________
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.
The date of this agreement is __________________________________________________.
Consent of Supporter(s)
Supporter #1: I, ______________________________ (name of supporter), consent to act as a supporter under this agreement, and acknowledge my responsibilities under RSA 464-D.
*
(Signature of supporter)
(Printed name of supporter).
My relationship to the principal is: ____________________.
Supporter #2: I, _________________________ (name of supporter), consent to act as a supporter under this agreement, and acknowledge my responsibilities under RSA 464-D.
*
(Signature of supporter)
(Printed name of supporter).
My relationship to the principal is: ____________________.
Additional supporters may be added below as necessary.
Consent of Monitor
I, ______________________________ (name of monitor), consent to act as a monitor under this agreement, and acknowledge my responsibilities under RSA 464-D.
*
(Signature of monitor)
(Printed name of monitor).
My relationship to the principal is: _________________________.
Consent of the Principal
Wait until a notary or 2 witnesses are there to watch you sign.
*
(My signature)
(My printed name).
Witnesses or Notary.
*
(Witness signature)
(Printed name of witness ).
*
(Witness signature)
(Printed name of witness )
RSA 464-D:16
2021, 206 : 2 , Pt. VI, Sec. 15, eff. Oct. 9, 2021.