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Health, Education And Life Planning (Help) Affidavit - Hillsborough County Board Of County Commissioners Page 2

HILLSBOROUGH COUNTY AND CITY OF TAMPA

HEALTH, EDUCATION AND LIFE PLANNING (HELP) AFFIDAVIT

Designating A Support Person Pursuant To Hillsborough County Ordinance No. 14-32

We the undersigned co-affiants declare that we are at least 18 years old and competent to enter into

contracts, and further declare and designate each other as our support person with the following rights,

indicated by initialing the spaces below.

(The same rights must be designated to each party.)

INITIALS OF CO-AFFIANTS

Health Care Surrogate, under Florida Statute Chapter 765. (By initialing this option, I understand that in the

event that I have been determined to be incapacitated to provide informed consent for medical treatment and

surgical and diagnostic procedures, I designate my above-named Support Person for healthcare decisions. I

understand that this designation will permit my healthcare surrogate to make healthcare decisions and to

provide, withhold, or withdraw consent on my behalf; to apply for public benefits to defray the costs of

healthcare; and to authorize my admission to or transfer from a healthcare facility. I further affirm that this

designation is being made on my own free will and is not being made as a condition of treatment or admission to

a healthcare facility.)

Health Care Facility visitation rights

Correctional Facility visitation rights

Pre-need Guardian under Florida law

Legally authorized representative to make funeral/burial decisions under Chapters 406, 497 and 732 Florida

Statutes, or as otherwise provided by law.

Access to educational records and involvement in the myriad of proceedings and decisions related to the

education of a minor child who is my dependent

Below are the names of our dependents, whom we swear and affirm to be (1) our biological, adopted, or foster child(ren); or

(2) our dependent(s) as defined under applicable Internal Revenue Service Regulation; or ( 3) our ward(s) as determined

a guardianship or other legal proceeding.

List of dependents Affiant 1:

List of dependents Affiant 2:

Person to be notified in the event of an emergency:

Affiant 1:

Affiant 2:

Name:

Address:

Phone (Optional):

Health, Education And Life Planning (Help) Affidavit - Hillsborough County Board Of County Commissioners Page 2