Common use of Revocation and Modification Clause in Contracts

Revocation and Modification. At any time, I may end or change this Agreement by signing a form created by SDMNY that must be witnessed. (See "Attachment C" and "Attachment D.") SIGNATURE AND ACKNOWLEDGMENT BY THE DECISION-MAKER: In Witness Whereof I have hereunto signed my name on the day of , 20 . Signature STATE OF NEW YORK ) ) ss: COUNTY OF ) On the day of , 20 , before me, the undersigned, personally appeared , personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her capacity, and that by his/her signature on the instrument, the individual, or the person upon behalf of which the individual acted, executed the instrument. Notary Public ATTESTATION AND SIGNATURE BY SUPPORTERS SUPPORTER # : I, , residing at , have read and understand the Agreement. I recognize and honor 's right to make her or his own decisions. By virtue of signing this Agreement, I fully commit to support her or him in exercising that right. In that role, I will not act as a substitute decision-maker, I will avoid conflicts of interest, and I will not exert undue influence. Signature STATE OF NEW YORK ) ) ss: COUNTY OF ) On the day of , 20 , before me, the undersigned, personally appeared , personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her capacity, and that by his/her signature on the instrument, the individual, or the person upon behalf of which the individual acted, executed the instrument. _______________________________ Notary Public SUPPORTER # : I, , residing at , have read and understand the Agreement. I recognize and honor 's right to make her or his own decisions. By virtue of signing this Agreement, I fully commit to support her or him in exercising that right. In that role, I will not act as a substitute decision-maker, I will avoid conflicts of interest, and I will not exert undue influence. Signature STATE OF NEW YORK ) ) ss: COUNTY OF ) On the day of , 20 , before me, the undersigned, personally appeared , personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her capacity, and that by his/her signature on the instrument, the individual, or the person upon behalf of which the individual acted, executed the instrument. Notary Public [NOTE TO DECISION-MAKER: Expand Section 9 as needed for different Supporters.] SIGNATURE AND ACKNOWLEDGMENT BY THE FACILITATOR: I, , acted as the SDMNY-trained facilitator for the Decision-Maker in the process leading up to signing this Agreement. Signature STATE OF NEW YORK ) ) ss: COUNTY OF ) On the day of , 20 , before me, the undersigned, personally appeared , personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her capacity, and that by his/her signature on the instrument, the individual, or the person upon behalf of which the individual acted, executed the instrument. Notary Public SDMNY PROCESS OVERVIEW Borrowing from the experience of pilot projects around the world and the academic and practical expertise of Hunter/CUNY faculty associates, and in consultation with the New York Alliance for Inclusion and Innovation and Arc Westchester, SDMNY has developed a facilitation model by which persons with developmental disabilities can choose trusted persons-often family members, neighbors or friends-to support them in making decisions in a variety of areas. In the SDMNY process, a trained facilitator, supervised by an experienced mentor, works with the person with developmental disability (the "Decision-Maker") and his or her chosen supporters to negotiate and formalize an agreement, the Supported Decision-Making Agreement, or SDMA.

Revocation and Modification. At any time, I may end or change this Agreement by signing a form created by SDMNY that must be witnessed. (See "Attachment C" and "Attachment D.") SIGNATURE AND ACKNOWLEDGMENT BY THE DECISION-MAKER: I, bold, italicize, underline______________, residing at bold, italicize, underline _________________affirm that: I have read and understand the Agreement that I have made with my Supporters and the assistance of an SDMNY Facilitator; I am 18 years old or older; I am choosing to exercise the right to make my own decisions with the support of trusted persons in my life; I want my Supporters to support me as described in this Agreement; and I want third parties (third parties are other people who may see this Agreement) to rely on this Agreement and respect my right to make my own decisions with the assistance of my Supporters. In Witness Whereof I have hereunto signed my name on the day of , 20 . Signature STATE OF NEW YORK ) ) ss: COUNTY OF ) On the day of , 20 , before me, the undersigned, personally appeared , personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her capacity, and that by his/her signature on the instrument, the individual, or the person upon behalf of which the individual acted, executed the instrument. Notary Public ATTESTATION AND SIGNATURE BY SUPPORTERS SUPPORTER # : I, , residing at , have read and understand the Agreement. I recognize and honor 's right to make her or his own decisions. By virtue of signing this Agreement, I fully commit to support her or him in exercising that right. In that role, I will not act as a substitute decision-maker, I will avoid conflicts of interest, and I will not exert undue influence. Signature STATE OF NEW YORK ) ) ss: COUNTY OF ) On the day of , 20 , before me, the undersigned, personally appeared , personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her capacity, and that by his/her signature on the instrument, the individual, or the person upon behalf of which the individual acted, executed the instrument. _______________________________ Notary Public SUPPORTER # : I, , residing at , have read and understand the Agreement. I recognize and honor 's right to make her or his own decisions. By virtue of signing this Agreement, I fully commit to support her or him in exercising that right. In that role, I will not act as a substitute decision-maker, I will avoid conflicts of interest, and I will not exert undue influence. Signature STATE OF NEW YORK ) ) ss: COUNTY OF ) On the day of , 20 , before me, the undersigned, personally appeared , personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her capacity, and that by his/her signature on the instrument, the individual, or the person upon behalf of which the individual acted, executed the instrument. Notary Public [NOTE TO DECISION-MAKER: Expand Section 9 as needed for different Supporters.] SIGNATURE AND ACKNOWLEDGMENT BY THE FACILITATOR: I, , acted as the SDMNY-trained facilitator for the Decision-Maker in the process leading up to signing this Agreement. Signature STATE OF NEW YORK ) ) ss: COUNTY OF ) On the day of , 20 , before me, the undersigned, personally appeared , personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her capacity, and that by his/her signature on the instrument, the individual, or the person upon behalf of which the individual acted, executed the instrument. Notary Public SDMNY PROCESS OVERVIEW Borrowing from the experience of pilot projects around the world and the academic and practical expertise of Hunter/CUNY faculty associates, and in consultation with the New York Alliance for Inclusion and Innovation and Arc Westchester, SDMNY has developed a facilitation model by which persons with developmental disabilities can choose trusted persons-often family members, neighbors or friends-to support them in making decisions in a variety of areas. In the SDMNY process, a trained facilitator, supervised by an experienced mentor, works with the person with developmental disability (the "Decision-Maker") and his or her chosen supporters to negotiate and formalize an agreement, the Supported Decision-Making Agreement, or SDMA.:

Revocation and Modification. At any time, I may end or change this Agreement by signing a form created by SDMNY that must be witnessednotarized. (See "“Attachment C" ” and "“Attachment D."”) SIGNATURE AND ACKNOWLEDGMENT BY THE DECISION-MAKER: In Witness Whereof I have hereunto signed my name on the day of , 20 . Signature STATE OF NEW YORK ) ) ss: COUNTY OF ) On the day of , 20 , before me, the undersigned, personally appeared , personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her capacity, and that by his/her signature on the instrument, the individual, or the person upon behalf of which the individual acted, executed the instrument. Notary Public ATTESTATION AND SIGNATURE BY SUPPORTERS SUPPORTER # : I, , residing at , have read and understand the Agreement. I recognize and honor 's right to make her or his own decisions. By virtue of signing this Agreement, I fully commit to support her or him in exercising agree that right. In that role, I will provide support in accordance with the Agreement and not act as a substitute decision-maker. In that role, I will agree to avoid conflicts of interest, interest and I will not to exert undue influence. Signature STATE OF NEW YORK ) ) ss: COUNTY OF ) On the day of , 20 , before me, the undersigned, personally appeared , personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her capacity, and that by his/her signature on the instrument, the individual, or the person upon behalf of which the individual acted, executed the instrument. _______________________________ Notary Public SUPPORTER # : Notary Public I, , residing at , have read and understand the Agreement. I recognize and honor 's right to make her or his own decisions. By virtue of signing this Agreement, I fully commit to support her or him in exercising agree that right. In that role, I will provide support in accordance with the Agreement and not act as a substitute decision-maker. In that role, I will agree to avoid conflicts of interest, interest and I will not to exert undue influence. Signature STATE OF NEW YORK ) ) ss: COUNTY OF ) On the day of , 20 , before me, the undersigned, personally appeared , personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her capacity, and that by his/her signature on the instrument, the individual, or the person upon behalf of which the individual acted, executed the instrument. Notary Public [NOTE TO DECISION-MAKER: Expand Section 9 as needed for different Supporters.] SIGNATURE AND ACKNOWLEDGMENT BY THE FACILITATOR: I, , acted as the SDMNY-trained facilitator for the Decision-Maker in the process leading up to signing this Agreement. Signature STATE OF NEW YORK ) ) ss: COUNTY OF ) On the day of , 20 , before me, the undersigned, personally appeared , personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her capacity, and that by his/her signature on the instrument, the individual, or the person upon behalf of which the individual acted, executed the instrument. Notary Public SDMNY PROCESS OVERVIEW Borrowing from the experience of pilot projects around the world and the academic and practical expertise of Hunter/CUNY faculty associates, and in consultation with the New York Alliance for Inclusion and Innovation and Arc Westchester, SDMNY has developed a facilitation model by which persons with developmental disabilities can choose trusted persons-—often family members, neighbors or friends-—to support them in making decisions in a variety of areas. In the SDMNY process, a trained facilitator, supervised by an experienced mentor, works with the person with developmental disability (the "“Decision-Maker"”) and his or her chosen supporters to negotiate and formalize an agreement, the Supported Decision-Making Agreement, or SDMA.

Revocation and Modification. At any time, I may end or change this Agreement by signing a form created by SDMNY that must be witnessed. (See "“Attachment C" ” and "“Attachment D."”) SIGNATURE AND ACKNOWLEDGMENT BY THE DECISION-MAKER: In Witness Whereof I have hereunto signed my name on the day of , 20 . Signature STATE OF NEW YORK ) ) ss: COUNTY OF ) On the day of , 20 , before me, the undersigned, personally appeared , personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her capacity, and that by his/her signature on the instrument, the individual, or the person upon behalf of which the individual acted, executed the instrument. Notary Public ATTESTATION AND SIGNATURE BY SUPPORTERS SUPPORTER # : I, , residing at , have read and understand the Agreement. I recognize and honor 's ’s right to make her or his own decisions. By virtue of signing this Agreement, I fully commit to support her or him in exercising that right. In that role, I will not act as a substitute decision-maker, I will avoid conflicts of interest, and I will not exert undue influence. Signature STATE OF NEW YORK ) ) ss: COUNTY OF ) On the day of , 20 , before me, the undersigned, personally appeared , personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her capacity, and that by his/her signature on the instrument, the individual, or the person upon behalf of which the individual acted, executed the instrument. _______________________________ Notary Public SUPPORTER # : Notary Public I, , residing at , have read and understand the Agreement. I recognize and honor 's ’s right to make her or his own decisions. By virtue of signing this Agreement, I fully commit to support her or him in exercising that right. In that role, I will not act as a substitute decision-maker, I will avoid conflicts of interest, and I will not exert undue influence. Signature STATE OF NEW YORK ) ) ss: COUNTY OF ) On the day of , 20 , before me, the undersigned, personally appeared , personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her capacity, and that by his/her signature on the instrument, the individual, or the person upon behalf of which the individual acted, executed the instrument. Notary Public [NOTE TO DECISION-MAKER: Expand Section 9 as needed for different Supporters.] SIGNATURE AND ACKNOWLEDGMENT BY THE FACILITATOR: I, , acted as the SDMNY-trained facilitator for the Decision-Maker in the process leading up to signing this Agreement. Signature STATE OF NEW YORK ) ) ss: COUNTY OF ) On the day of , 20 , before me, the undersigned, personally appeared , personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her capacity, and that by his/her signature on the instrument, the individual, or the person upon behalf of which the individual acted, executed the instrument. Notary Public SDMNY PROCESS OVERVIEW Borrowing from the experience of pilot projects around the world and the academic and practical expertise of Hunter/CUNY faculty associates, and in consultation with the New York Alliance for Inclusion and Innovation and Arc Westchester, SDMNY has developed a facilitation model by which persons with developmental disabilities can choose trusted persons-—often family members, neighbors or friends-—to support them in making decisions in a variety of areas. In the SDMNY process, a trained facilitator, supervised by an experienced mentor, works with the person with developmental disability (the "“Decision-Maker"”) and his or her chosen supporters to negotiate and formalize an agreement, the Supported Decision-Making Agreement, or SDMA.

Revocation and Modification. At any time, I may end or change this Agreement by signing a form created by SDMNY that must be witnessed. (See "Attachment C" and "Attachment D.") SIGNATURE AND ACKNOWLEDGMENT BY THE DECISION-MAKER: In Witness Whereof I have hereunto signed my name on the day of , 20 . Signature STATE OF NEW YORK ) ) ss: COUNTY OF ) On the day of , 20 , before me, the undersigned, personally appeared , personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her capacity, and that by his/her signature on the instrument, the individual, or the person upon behalf of which the individual acted, executed the instrument. Notary Public ATTESTATION AND SIGNATURE BY SUPPORTERS SUPPORTER # : I, , residing at , have read and understand the Agreement. I recognize and honor 's right to make her or his own decisions. By virtue of signing this Agreement, I fully commit to support her or him in exercising that right. In that role, I will not act as a substitute decision-maker, I will avoid conflicts of interest, and I will not exert undue influence. Signature STATE OF NEW YORK ) ) ss: COUNTY OF ) On the day of , 20 , before me, the undersigned, personally appeared , personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her capacity, and that by his/her signature on the instrument, the individual, or the person upon behalf of which the individual acted, executed the instrument. _______________________________ Notary Public SUPPORTER # : Notary Public I, , residing at , have read and understand the Agreement. I recognize and honor 's right to make her or his own decisions. By virtue of signing this Agreement, I fully commit to support her or him in exercising that right. In that role, I will not act as a substitute decision-maker, I will avoid conflicts of interest, and I will not exert undue influence. Signature STATE OF NEW YORK ) ) ss: COUNTY OF ) On the day of , 20 , before me, the undersigned, personally appeared , personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her capacity, and that by his/her signature on the instrument, the individual, or the person upon behalf of which the individual acted, executed the instrument. Notary Public [NOTE TO DECISION-MAKER: Expand Section 9 as needed for different Supporters.] SIGNATURE AND ACKNOWLEDGMENT BY THE FACILITATOR: I, , acted as the SDMNY-trained facilitator for the Decision-Maker in the process leading up to signing this Agreement. Signature STATE OF NEW YORK ) ) ss: COUNTY OF ) On the day of , 20 , before me, the undersigned, personally appeared , personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her capacity, and that by his/her signature on the instrument, the individual, or the person upon behalf of which the individual acted, executed the instrument. Notary Public SDMNY PROCESS OVERVIEW Borrowing from the experience of pilot projects around the world and the academic and practical expertise of Hunter/CUNY faculty associates, and in consultation with the New York Alliance for Inclusion and Innovation and Arc Westchester, SDMNY has developed a facilitation model by which persons with developmental disabilities can choose trusted persons-often family members, neighbors or friends-to support them in making decisions in a variety of areas. In the SDMNY process, a trained facilitator, supervised by an experienced mentor, works with the person with developmental disability (the "Decision-Maker") and his or her chosen supporters to negotiate and formalize an agreement, the Supported Decision-Making Agreement, or SDMA.

Revocation and Modification. At any time, I may end or change this Agreement by signing a form created by SDMNY that must be witnessed. (See "Attachment C" and "Attachment D.") SIGNATURE AND ACKNOWLEDGMENT BY THE DECISION-MAKER: I, ______________, residing at __________________affirm that: I have read and understand the Agreement that I have made with my Supporters and the assistance of an SDMNY Facilitator; I am 18 years old or older; I am choosing to exercise the right to make my own decisions with the support of trusted persons in my life; I want my Supporters to support me as described in this Agreement; and I want third parties (third parties are other people who may see this Agreement) to rely on this Agreement and respect my right to make my own decisions with the assistance of my Supporters. In Witness Whereof I have hereunto signed my name on the day of , 20 . Signature STATE OF NEW YORK ) ) ss: COUNTY OF ) On the day of , 20 , before me, the undersigned, personally appeared , personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her capacity, and that by his/her signature on the instrument, the individual, or the person upon behalf of which the individual acted, executed the instrument. Notary Public ATTESTATION AND SIGNATURE BY SUPPORTERS SUPPORTER # : I, , residing at , have read and understand the Agreement. I recognize and honor 's right to make her or his own decisions. By virtue of signing this Agreement, I fully commit to support her or him in exercising that right. In that role, I will not act as a substitute decision-maker, I will avoid conflicts of interest, and I will not exert undue influence. Signature STATE OF NEW YORK ) ) ss: COUNTY OF ) On the day of , 20 , before me, the undersigned, personally appeared , personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her capacity, and that by his/her signature on the instrument, the individual, or the person upon behalf of which the individual acted, executed the instrument. _______________________________ Notary Public SUPPORTER # : I, , residing at , have read and understand the Agreement. I recognize and honor 's right to make her or his own decisions. By virtue of signing this Agreement, I fully commit to support her or him in exercising that right. In that role, I will not act as a substitute decision-maker, I will avoid conflicts of interest, and I will not exert undue influence. Signature STATE OF NEW YORK ) ) ss: COUNTY OF ) On the day of , 20 , before me, the undersigned, personally appeared , personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her capacity, and that by his/her signature on the instrument, the individual, or the person upon behalf of which the individual acted, executed the instrument. Notary Public [NOTE TO DECISION-MAKER: Expand Section 9 as needed for different Supporters.] SIGNATURE AND ACKNOWLEDGMENT BY THE FACILITATOR: I, , acted as the SDMNY-trained facilitator for the Decision-Maker in the process leading up to signing this Agreement. Signature STATE OF NEW YORK ) ) ss: COUNTY OF ) On the day of , 20 , before me, the undersigned, personally appeared , personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her capacity, and that by his/her signature on the instrument, the individual, or the person upon behalf of which the individual acted, executed the instrument. Notary Public SDMNY PROCESS OVERVIEW Borrowing from the experience of pilot projects around the world and the academic and practical expertise of Hunter/CUNY faculty associates, and in consultation with the New York Alliance for Inclusion and Innovation and Arc Westchester, SDMNY has developed a facilitation model by which persons with developmental disabilities can choose trusted persons-often family members, neighbors or friends-to support them in making decisions in a variety of areas. In the SDMNY process, a trained facilitator, supervised by an experienced mentor, works with the person with developmental disability (the "Decision-Maker") and his or her chosen supporters to negotiate and formalize an agreement, the Supported Decision-Making Agreement, or SDMA.