Informal decision-maker details

Use this form to advise the Department of Housing of arrangements you have with a family member or close friend who helps you make decisions (i.e. personal, lifestyle or financial matters). The completion of this form gives the department consent to discuss your personal details with your informal decision- maker to assist in housing and tenancy-related matters for the period specified below.
An informal decision-maker for an adult whose capacity to make decisions is impaired, is a person who is a member of the adult’s informal support network. This person may be a member of the adult’s family or a close friend of the adult. If an informal decision-maker supports you to make decisions, you are requested to complete this form providing contact details for that person and describing the nature of the agreement between you.
For more information, or to arrange an interpreter, contact your nearest Housing Service Centre.
Your contact details
Name

Address
Contact numbers
(business hours)	(after hours)	(mobile)
Contact details of your informal decision-maker
Name Address
Contact numbers

Email

(business hours)	(after hours)	(mobile)

How would you prefer to be contacted (phone, SMS, email, etc)? You may choose more than one.

Agreement

agree that
(your name)	(name of informal decision-maker)

may speak on my behalf and represent my best interests to the department about lifestyle decisions in regard to my tenancy.
may speak on my behalf and represent my best interests to the department about financial decisions in regard to my tenancy (e.g. rent payment).
may perform duties on my behalf as listed in the attached sheet.

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The first point of contact to discuss matters relating to my application or tenancy should be: (please tick) Me	My informal decision-maker

This agreement is valid from
Privacy Notice

(date) to

(date) (maximum period of five years)

The Department of Housing is collecting your personal information so we may provide you with housing assistance. To assist you with your housing needs and services, your personal information may be disclosed to partner agencies, service providers, local governments and non-governmental agencies that now, or will, provide you with housing and/or support services. Unless authorised or required by law, your personal information will not be disclosed to any other third party without your consent. More information about the Department’s privacy obligations is available on our website at www.housing.qld.gov.au.
Declaration and signatures
To the best of my/our knowledge, the information provided on and in conjunction with this form is true and correct. I/We understand that it is an offence under the Housing Act 2003 to knowingly provide to the Department of Housing false or misleading information that may influence decisions about my/our eligibility for housing services.

Your signature	Date	Informal decision-maker signature	Date

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Please return completed form to your nearest Housing Service Centre.

Department of Housing
www.housing.qld.gov.au

PH005-2 (27/07/2023)