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: _________________