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FORM 5
Adult Guardianship and Trusteeship Act
Clerk’s Stamp
COURT FILE NUMBER / <court file number>
COURT / Court of Queen’s Bench of Alberta
(Surrogate Matter)
JUDICIAL CENTRE / <judicial centre>
FULL NAME OF THE PERSON WHOM THE APPLICATION IS ABOUT (“THE ADULT”) / <name of adult>
DOCUMENT / Order – Appointment of
Co-Decision-Maker
APPLICANT / <name of applicant>
APPLICANT’S ADDRESS FOR SERVICE AND CONTACT INFORMATION: / [Order prepared by:]
Date on which Order wasgranted: / , 20 / .
Location at which Order was granted: / , Alberta.
Name of Judge who granted this Order: / The Honourable Justice

Include only those provisions that are appropriate for the application presented to the Court, and delete those provisions which do not apply. Standard provisions should be modified as appropriate to the context. Help text (including this box) should also be deleted from this form of order before it is presented to the Court.

THE COURT:

  • has reviewed the consent of the adult endorsed at the end of this order and the written material filed in this application;
  • has considered the application in the absence of the applicant and any other person, being satisfied that
  • no person entitled to do so has requested a hearing in accordance with the regulations, and
  • it is unnecessary to hold a hearing;
  • has determined that
  • the adult [choose one]

is 18 years of age or older;

will attain the age of 18 within 12 months of the date of the application;

  • the conditions for appointment of a co-decision-makerare satisfied, namely,
  • the adult’s capacity to make decisions about the personal matters referred to in this order is significantly impaired;
  • the adult would have the capacity to make decisions about the personal matters referred to in this order if provided with appropriate guidance and support;
  • less intrusive and less restrictive alternative measures than a co-decision-making order, including a supported decision-making authorization, have been considered or have been implemented and would not likely be or have not been effective to meet the needs of the adult;
  • it is in the adult’s best interests for a co-decision-maker to be appointed;

AND THE COURT ORDERS:

1.Appointment of co-decision-maker

[Include in all cases]

1.1

/ <name of co-decision-maker(s)> / is (are) appointed co-decision-maker(s) of
<name of adult> / .

[Include in all cases]

1.2

/ The adult is required to make decisions with respect to the following personal matters with the co-decision-maker:
the adult’s health care;
where, with whom and under what conditions the adult is to live, either permanently or temporarily;
with whom the adult may associate;
the adult’s participation in social activities;
the adult’s participation in any educational, vocational or other training;
the adult’s employment;
the carrying on of any legal proceeding that does not relate primarily to the financial matters of the adult;
the following personal matter(s) of the adult that the Court considers necessary, namely:
  • <specified matters>

[Include only if requested in application]

1.3A contract made by the adult after the date of this order with respect to the above personal matters is voidable unless it is in writing and signed by the adult and the co-decision-maker.

[Include only if requested in application]

1.4

/ The co-decision-makers must act jointly with respect to the following personal matters of the adult:
  • <specified matters>

[Include only if requested in application]

1.5

/ The co-decision-makers must act successively in the following manner:
<specify manner>
with respect to the following personal matters of the adult:
  • <specified matters>

[Include in all cases]

1.6

/ This order is subject to the following conditions, limits or requirements:
  • <reserved for conditions, limits or requirements considered appropriate by Court>

[Include if the adult is subject to a guardianship order that is to be terminated]

1.7

/ The guardianship order dated / <date of order> / is hereby terminated.

[Include in all cases]

1.8

/ <name of co-decision-maker(s)> / must apply for a review of this co-decision-making order
within / <#> / years of the date of this order, OR
as circumstances require (no fixed date),
AND in any event
  • if there has been a significant change in the needs, circumstances or capacity of the adult that the co-decision-maker considers would make a variation or termination of the order in the adult’s best interests, OR
  • if there has been a change in circumstances that affects the co-decision-maker’s ability to exercise the authority or carry out the duties and responsibilities of a co-decision-maker or suitability to be a co-decision-maker for theadult.

2.Costs of application

2.1

/ The following order is made regarding costs (legal fees and disbursements) of this application:
Legal fees for this application[choose one]
in the amount of / $<amount>
to be assessed
plus reasonable disbursements shall be paid by / <person or source to pay costs>
Reasonable disbursements only shall be paid by / <person or source to pay disbursements>
No order is made regarding payment of legal fees or disbursements.

3.Other matters

3.1

/ All requirements of the Act and regulations regarding service or sending of notice of this application are deemed to have been satisfied, including requirements as to:
  • the persons to be notified of this application;
  • the documents to be served or sent to such persons;
  • the manner of and time for serving or sending documents

Notice of this application to the following persons is dispensed with:
Name / Relationship to Adult

3.2

/ The following direction is given regarding service of this order:
Except as otherwise provided below, a copy of this order must be sent by ordinary mail to the adult, the review officer, and every other person who was notified of this application.
A copy of this order must be served on / <name of person to be served>
by the following method of service: / <method of service>

[Include if application is made in respect of a person who has not attained the age of majority as provided for by section 11(1) of the Act]

3.3In accordance with section 11(2)(b) of the Act, this order does not take effect until the person in respect of whom it is made attains the age of majority.

Justice of the Court of Queen’s Bench
of Alberta
Consented to by:
Signature of the Adult / Signature of Witness
Date Signed / Print Full Name of Witness