Legal Impaired Document

Legal Impaired Document

This Legal Impaired Document (the Agreement) is made and entered into as of Effective Date: , by and between Principal Name: of Address: and Representative Name: of Address: .

Recitals

WHEREAS, Principal has a cognitive, sensory, mobility, communication, or other impairment that may materially affect the Principal's ability to understand, review, or execute certain legal documents and transactions (Impairment); and

WHEREAS, Representative is willing to provide specified assistance, accommodations, or limited authority to facilitate the Principal's informed consent and to act only as provided in this Agreement; and

WHEREAS, the parties wish to set forth the scope of assistance, limitations on authority, and the measures taken to document the Principal's capacity and informed decision-making.

NOW, THEREFORE, in consideration of the mutual covenants contained herein, the parties agree as follows:

1. Definitions

1.1 "Impairment" means the physical, cognitive, sensory, or other condition described by the Principal in this Agreement and evaluated in the capacity assessment. The Principal's description of impairment:

1.2 "Capacity Assessment" means any written, dated evaluation by a licensed professional used to document the Principal's decision-making capacity. Assessment performed by: on .

2. Acknowledgment of Impairment and Assistance

2.1 The Principal acknowledges the existence of the Impairment and consents to the accommodations and limited assistance described in this Agreement. The Principal confirms that the Principal has received the accommodations listed below and that such accommodations were reasonably necessary to facilitate understanding and communication.

2.2 Accommodations provided (check all that apply): Written explanation in plain language Oral explanation and summary Assistive device or communication aid Opportunity to consult independent counsel

2.3 Additional description of assistance provided:

3. Scope of Authority

3.1 The Representative's authority is strictly limited to the tasks expressly listed below and to no other decisions unless subsequently agreed in writing by the Principal or a court of competent jurisdiction. Authorized tasks:

3.2 The Representative shall act only to the extent necessary to implement the agreed accommodations and shall preserve the Principal's autonomy to the fullest extent practicable. The Representative will not execute any durable power of attorney, transfer title to real property, or make testamentary changes on behalf of the Principal without separate, explicit written authorization.

4. Limitations; Duration; Termination

4.1 This Agreement shall commence on the Effective Date and shall continue until Termination Date: , unless earlier terminated as provided herein.

4.2 Either party may terminate this Agreement upon written notice to the other party if the terminating party reasonably determines that the accommodations are no longer necessary, the Representative has exceeded the scope of authority, or the Principal revokes consent. Termination shall not invalidate acts lawfully performed under this Agreement prior to the effective date of termination.

5. Representations and Warranties

5.1 Each party represents and warrants that the party has the legal capacity to enter into this Agreement and that the information provided in this Agreement is true and correct to the best of that party's knowledge. The Representative further warrants that the Representative will exercise any authority granted in good faith and in the best interests of the Principal.

6. Confidentiality

6.1 The parties shall maintain the confidentiality of medical, assessment, and other sensitive information disclosed in connection with this Agreement, except as required by law or court order. The Representative shall only use such information to the extent necessary to perform the representative tasks authorized by this Agreement.

7. Notices

Notices to Principal

Notices to Representative

8. Amendments; Waiver; Counterparts

8.1 This Agreement may be amended only by a written instrument signed by both parties. No failure or delay by either party in exercising any right under this Agreement will constitute a waiver of that right, unless a written waiver is signed by the party granting the waiver.

8.2 This Agreement may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one instrument.

9. Governing Law; Entire Agreement; Severability

9.1 Governing Law. This Agreement shall be governed by and construed in accordance with the laws of the jurisdiction selected by the parties:

9.2 Entire Agreement. This Agreement constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements and understandings, both written and oral.

9.3 Severability. If any provision of this Agreement is held to be invalid, illegal, or unenforceable in any respect, the validity, legality, and enforceability of the remaining provisions will not be affected.

10. Certification

By signing below, the Principal certifies that the Principal has read or had read to the Principal the foregoing Agreement, understands its terms, and knowingly and voluntarily consents to the accommodations and limited authority set forth herein. The Representative certifies that the Representative will act within the scope of authority set forth and will preserve the Principal's autonomy to the maximum extent possible.

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