For more information about Representation
Agreements, see the booklet on Representation
A Representation Agreement is a written
agreement between you and your Representatives.
You can give your Representatives the power to
make decisions for you for day-to-day decisions
about your money or your personal affairs.
List the decisions you want your Representatives
to make for you in this Agreement.
If you want to have a legally valid Representation
Agreement you must use this form and you must be
at least 19 years of age. Also, you must be able to
understand the “nature and effect” of this
1. This is the Representation Agreement of
Name ____________________________________________ Date of birth __________________________
2. I understand that this agreement takes effect when it has been signed by everyone listed in section 10 of
this agreement and is only in effect as long as I continue to understand the “nature and effect” of this
3. Purpose of Agreement
The reasons I want to have Representatives make some decisions for me are because I:
(Examples: • have trouble communicating • need help with banking • have trouble putting my decisions into
Health and Social Services
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