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BRITISH COLUMBIA
REPRESENTATION AGREEMENT WITH LIMITED POWERS

Made by          

of                          , British Columbia.                                

1.            Appointment of representative and alternate

a)   I appoint          of         , British Columbia, as my personal and health-care representative with the limited powers contained in section 7 of the Representation Agreement Act.

b)   If  my representative is unwilling to act, dies, or for any other reason is unable to act, then I appoint          of          , British Columbia, as my representative in his or her place.

2.            Coming into effect

a)      This Representation Agreement will only be in effect if I am unable to make decisions independently about my health care, personal care, or financial affairs due to lack of capacity.

b)   A declaration by          of         ,  British Columbia, will be sufficient proof that I am unable to make decisions independently about my health care, personal care, or financial affairs.

c)   If the person named above is unable or unwilling to make a determination about my ability to make decisions independently, or cannot be reached after every reasonable effort has been made, then a written declaration signed by two physicians who are familiar with my circumstances will suffice.

3.         Duties, powers, and liability of representative and alternate

            My representative and alternate have only those limited powers set out in section 7 of the Representation Agreement Act, namely power to make decisions about —

a)   my personal care;

b)   routine management of my financial affairs including —

i.      payment of bills;

ii.      receipt and deposit of pension and other income;

iii.      purchases of food, accommodation, and other services necessary for personal care; and

iv.      making investments;

c)   major health care and minor health care as defined in the Health-Care (Consent) and Care Facility (Admission) Act but not including the kinds of health care prescribed under section 34(2)(f) of that act;

d)   obtaining legal services and instructing counsel to commence proceedings except divorce proceedings, or to continue, compromise, defend, or settle any legal proceedings;

e)   accept a care facility proposal under the Health-Care (Consent) and Care Facility (Admission) Act but only if the facility is a family care home, group home for the mentally handicapped, or mental health boarding home.

Provided that my representative and alternate are subject to all relevant sections of the Representation Agreement Act.

4.         My instructions about end-of-life treatment

            (Insert clause chosen from Sample 1.)

5.            Revocation

            I revoke any prior representation agreements.

6.            Monitor

I have the utmost faith in my representative and alternate and choose not to appoint a monitor. I understand that, in that case, this agreement is not effective unless I have consulted with a lawyer or notary who completes a consultation certificate and attaches it to this agreement. 

Signed and dated at                           , British Columbia,

this                    day of                           , 20                          .

(Signature of maker)                        (Print name of maker)

(Signature of representative)                        (Print name of representative)

(Signature of alternate representative)                        (Print name of alternate representative)

(Signature of witness)                        (Print name of witness)           

(Signature of witness)                        (Print name of witness)

CERTIFICATE OF REPRESENTATIVE

I,                       (name of representative),

of                      (address of representative)

Certify that:

1.   I am named as representative in the representation agreement made on the                of

              , 20              , by        (name of adult maker) of ___________________________________ (address of adult maker).

2.   I was 19 years of age or older on the date I signed the representation agreement referred to in this certificate.

3.   I am not a witness to the representation agreement.

4.   I have read and understand the duties and responsibilities of a representative as set out in section 16 of the Representation Agreement Act and I have agreed to accept these duties and responsibilities. I have also read and understand section 30 of the Representation Agreement Act and have no reason to make an objection.

(Signature of representative)

(Print name of representative) 

(Date)

CERTIFICATE OF ALTERNATE REPRESENTATIVE

I,                       (name of alternate representative),

of                      (address of alternate representative)

Certify that:

1.   I am named as alternate representative in the representation agreement made on the               of  

            , 20              , by        

(name of adult maker) of          (address of adult maker).

2.   I was 19 years of age or older on the date I signed the representation agreement referred to in this certificate.

3.   I am not a witness to the representation agreement.

4.   I have read and understand the duties and responsibilities of a representative as set out in section 16 of the Representation Agreement Act and I have agreed to accept these duties and responsibilities. I have also read and understand section 30 of the Representation Agreement Act and have no reason to make an objection.

(Signature of alternate representative)

(Print name of alternate representative)

(Date)

CONSULTATION CERTIFICATE

I,                       (name of lawyer or notary consulted),

of                      (address of lawyer or notary consulted)

Certify that:

1.   I am —

a)   a practising member in good standing of the Law Society of British Columbia, or

b)   a member of a prescribed class of persons under section 9(2)(a) of the Representation Agreement Act.    

2.   I was consulted by       (name of adult maker) of  

            (address of adult maker)

regarding the making of the agreement dated     day of               , 20              ,

under the Representation Agreement Act.

3.   The consultation took place on the                day of               , 20              , at

             (place of consultation).

4.   I explained the provisions of the Representation Agreement Act to the adult maker of the agreement and he/she appeared to understand the nature of the authority given to his/her representative and the effect of such authority.

(Signature of person consulted)

(Print name of person consulted)

(Date)

WITNESS CERTIFICATION

(For consulted person who acts as a witness)

I certify that:

1.   I witnessed the signing of the representation agreement described above by

             (name of adult maker).

2.   I understand independently or through an interpreter the form of communication used by the adult maker.

3.   I am not named in the agreement as a representative or alternate representative.

4.   I am not a spouse, child, or parent of anyone named in the agreement as a representative or alternate representative.

5.   I am not an employee or agent of a person named in the agreement as a representative or alternate representative.

(Signature of witness)

(Print name of witness)

(Date)

DECLARATION OF INCAPACITY BY DESIGNATED PERSON

I,                           ,

of                           , British Columbia, the person designated in the attached representation agreement to determine the adult maker’s capacity, declare that I am of the opinion that        (name of maker) is unable to make decisions independently about his/her health care, personal care, or financial affairs due to lack of capacity for the following reasons:

(Signature of designated person)

(Print name of designated person)

(Address of designated person)

(Date)