Informal Decision Maker Details Form-1066

INFORMAL DECISION MAKER DETAILS (Form-1066)
Please use this form to advise us of arrangements you have with a family member or close friend who helps you make decisions (i.e. personal, lifestyle or financial matters) This person may be a member of your family or a close friend. If an informal decision-maker supports you to make decisions, you are requested to complete this form providing contact details for that person and describing the nature of the agreement between you.
Your Contact Details
Name:

First NameLast Name
Address

Street Address

CityState

Post Code
Phone:
Contact details of your Informal Decision Maker
Name

First NameLast Name
Address

Street Address

CityState

Post Code
Phone:
Email:
example@example.com
How would you prefer to be contacted (phone, SMS, email, etc)? You may choose more than one.
Agreement:
Your First Name Your Last Name agree that Decision Maker First Name Decision Maker Last Name
May speak on my behalf and represent my best interests to Australian Quality Care about lifestyle decisions regarding my tenancy.May speak on my behalf and represent my best interests to Australian Quality Care about financial decisions regarding my tenancy (e.g. rent payment).May speak on behalf and represent my best interests regarding consent and additional services forms.May view my Resident Personal File which includes mail I've received, Public Trust information and appointment records.
The first point of contact to discuss matters relating to my application of tenancy should be: (Please tick)

MeMy informal decision maker
This agreement is valid from Date to Date maximum period of 5 years.
Declaration and signatures:
Your signature:

Clear
Date:

DayMonthYear
Date
Informal Decision Maker Signature:

Clear
Date:

DayMonthYear
Date
Should be Empty:

INFORMAL DECISION MAKER DETAILS (Form-1066)

Your Contact Details

Contact details of your Informal Decision Maker

Agreement:

Declaration and signatures: