Create Your Signature

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

Full Legal Name

Your Initials

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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

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Listed Signers

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

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

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Create Your Signature

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Listed Signers

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

LTSS Representative