Texas Statutory Supported Decision-Making Agreement Form (Page 2 of 2) in pdf

Texas Statutory Supported Decision-Making Agreement Form Page 2

Consent of Supporter

I, ________________________________ (name), consent to act as a supporter under this

agreement.

_______________________________________

________________________________

(Signature of Supporter)

(Printed Name of Supporter)

This agreement must be signed in front of two witnesses or a Notary Public.

_______________________________________

________________________________

(Witness 1 Signature)

(Printed Name of Witness 1)

_______________________________________

________________________________

(Witness 2 Signature)

(Printed Name of Witness 2)

OR Notary Public

State of

__________________

County of __________________

This document was acknowledged before me on ____________________ (date)

By __________________________________ and _________________________________

(Name of Adult with a Disability)

(Name of Supporter)

______________________________________

__________________________________

(Signature of Notary)

(Printed name of Notary)

(Seal, if any, of notary)

My commission expires: _________________

WARNING: PROTECTION FOR THE ADULT WITH A DISABILITY

If a person who receives a copy of this agreement or is aw are of the existence of this agreement has

cause to believe that the adult with a disability is being abused, neglected, or exploited by the

supporter, the person shall report the alleged abuse, neglect, or exploitation to the Department of

Family and Protective Services by calling the abuse hotline at 1-800-252-5400 or online at

Texas Statutory Supported Decision-Making Agreement Form Page 2