Form 55J

 

AN CHÚIRT CHUARDA
THE CIRCUIT COURT

 

     CIRCUIT                                                                                                    COUNTY OF 

Record number:

In the matter of the Assisted Decision-Making (Capacity) Act 2015 and in the matter of …………………..of ………………………………….

 

STATEMENT OF DECISION MAKING REPRESENTATIVE 

 

I, ______________________________________________________________, the / a

Decision Making Representative for the above Relevant Person confirm that I,

 

(a) understand and undertake to act in accordance with the powers conferred and the duties imposed on me by the Court, and

 

(b) understand and undertake to act in accordance with the guiding principles set out in section 8 of the Assisted Decision Making (Capacity) Act 2015.

 

 

 

Signed: ______________________________________________________________

 

Dated: _________________