Create Your Signature

Please fill in your name and email and then either draw or type your signature below.

Full Legal Name

Your Initials

Signature Type

Type Draw Upload Custom

Signature will be applied to the page. You will have a chance to review after signing.

Check this box to continue

I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.

Additional Signatures Required

Please provide accurate information below to ensure the delivery of the signed copies of the document.

Listed Signers

	Signer Details	Me?
Provider Representative
I'm not a signer listed above

SD Department of Human Services Division of Long Term Services and Supports

Print Document

Create Your Signature

Sign Now!

Please provide accurate information below to ensure the delivery of the signed copies of the document.

Listed Signers

Other Signers (The signers below will be invited to sign once the above signers have signed.)

LTSS Representative