A. An adult, without undue influence or coercion, may voluntarily enter into a supported decision-making agreement with a supporter under which the adult authorizes the supporter to do any or all of the following:

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1. Provide supported decision-making, including assisting the adult in understanding the options, responsibilities and consequences of the adult’s life decisions, without making those decisions on behalf of the adult.

2. Assist the adult in accessing, collecting and obtaining from any person information that is relevant to a given life decision, including medical, psychological, financial, education or treatment records.

3. Assist the adult in understanding the information described in paragraph 2 of this subsection.

4. Assist the adult in communicating the adult’s decisions to appropriate persons.

B. A supporter is not a surrogate decision-maker for the adult and does not have the authority to sign legal documents on behalf of the adult or bind the adult to a legal agreement.

C. The supported decision-making agreement shall set forth the rights, roles, duties, limitations and obligations of both the adult and the supporter who are entering into the agreement.

D. If the supporter intimidates or deceives the adult in procuring the supported decision-making agreement or any authority provided in the supported decision-making agreement, the supporter may be subject to criminal prosecution and civil penalties as otherwise provided by law.

E. The supporter may not receive compensation as a result of the supporter’s duties under a supported decision-making agreement. The supporter shall act without self-interest and shall avoid conflicts of interest.

F. A supported decision-making agreement must be signed by the adult and the supporter in the presence of two or more subscribing witnesses, who must be at least eighteen years of age, or a notary public, and the signature process is subject to the following requirements:

1. By witnessing the agreement, each witness or notary affirms that the witness or notary was present when the person dated and signed or marked the agreement, except as provided under paragraph 2 of this subsection, and that the person appeared to be of sound mind and free from duress at the time of execution of the agreement.

2. If a person is physically unable to sign or mark the agreement, the witness or notary shall verify on the document that the person directly indicated to the notary or witness that the agreement expressed the person’s wishes and that the person intended to adopt the agreement at that time.

G. A supported decision-making agreement extends until:

1. Terminated in writing by either party or by the terms of the supported decision-making agreement.

2. At any time the adult becomes an incapacitated person as defined in section 14-5101.

3. On the appointment of a guardian pursuant to article 3 of this chapter.

H. The supported decision-making agreement shall be in substantially the following form:

Supported Decision-Making Agreement

This agreement is governed by the Arizona supported decision-making agreement statute section 14-5722, Arizona Revised Statutes. For the purposes of this agreement, "decision-maker" means an adult with a disability who executes an agreement for the purpose of designating an individual to serve as the decision-maker’s supporter when the decision-maker makes certain decisions that are listed in the agreement.

Purpose of Agreement

The purpose of the supported decision-making agreement is to support and accommodate a decision-maker to make informed decisions and choices about certain aspects of the adult’s daily life.

Role of Supporter

To assist a decision-maker, a supporter may:

1. Assist the decision-maker with getting information to be able to understand available choices.

2. Assist the decision-maker in understanding choices so the decision-maker can make the best personal decisions.

3. Assist the decision-maker in communicating decisions to the right people and organizations.

Revocation or Termination of Agreement

A. The decision-maker or the supporter may revoke this agreement at any time.

B. This agreement terminates as a matter of law at any time the decision-maker becomes an incapacitated person as defined in section 14-5101, Arizona Revised Statutes.

C. This agreement terminates as a matter of law on the appointment of a guardian for any reason or purpose pursuant to Title 14, Chapter 5, Article 3, Arizona Revised Statutes.

D. If either the decision-maker or supporter has questions about the agreement, the decision-maker or supporter should speak with a lawyer before signing this supported decision-making agreement.

Important Information for Supporters About

the Limits to this Agreement

A. You may not make a decision for or on behalf of the decision-maker.

B. Neither you nor any organization for whom you are employed or serve as a volunteer may receive any financial support, remuneration or compensation, either directly or indirectly, for or related to your services and role as a supporter to the decision-maker.

C. When you agree to provide support to an adult under this supported decision-making agreement, you have a duty to and you shall:

1. Act in good faith.

2. Act with loyalty to the decision-maker.

3. Act without self-interest.

4. Avoid conflicts of interest.

5. Stop serving as a supporter at any time that you question the capacity of the decision-maker to continue making decisions even with your support.

6. Stop serving as a supporter at any time that the supported decision-making agreement is revoked by the decision-maker or you, or the agreement ends as a matter of law.

7. Respect the decision-maker’s relationships with friends and family members and not attempt to isolate or alienate the decision-maker from those friends and family members.

APPOINTMENT OF SUPPORTER

I ______________________________________, (name of adult, (the "decision-maker")), am of sound mind and enter into this agreement voluntarily.

My disabilities are: (describe briefly)

_________________________________________________________________________________________________________________________________________________________________________________________.

I choose _____________________________________________________ to be my supporter.

Supporter’s address:__________________________________________

Supporter’s telephone number:_________________________________

Supporter’s email address:____________________________________

SUPPORTER’S ROLE AND LIMITATIONS ON THAT ROLE

My supporter may help me with life decisions about each of the following which I have marked with an "X" (check those that apply):

Yes ___ No ___ Obtaining food, clothing and a place to live.

Yes ___ No ___ My physical health and health services.

Yes ___ No ___ My mental health and mental health services.

Yes ___ No ___ Managing my money or property.

Yes ___ No ___ Getting an education or other training.

Yes ___ No ___ Choosing and maintaining my services and supports.

Yes ___ No ___ Finding a job.

Yes ___ No ___ Other: ______________________________ (specify)

Yes ___ No ___ My supporters may see my private health information under the Health Insurance Portability and Accountability Act of 1996 (P.L. 104-191) if I first choose to provide a signed release.

Yes ___ No ___ My supporters may see my educational records under the Family Educational Rights and Privacy Act of 1974 (20 United States Code § 1232g) if I first choose to provide a signed release.

This agreement is effective when signed and will continue until ___________ (date) or until my supporter or I end the agreement or the agreement ends by operation of law, including the appointment of a guardian for me.

DECISION-MAKER’S SIGNATURE

Signed this __________ (day) of __________________ (month), ________ (year)

_____________________________ _______________________________

(signature of decision-maker) (printed name of decision-maker)

CONSENT OF SUPPORTER

I (name of supporter), _______________________________ consent to act as a Supporter under this agreement.

____________________________ _____________________________

(signature of supporter) (printed name of supporter)

This agreement must be signed in front of two

witnesses or a notary public

____________________________ _____________________________

(witness 1 signature) (printed name of witness 1)

____________________________ _____________________________

(witness 2 signature) (printed name of witness 2)

or

Notary Public

State of ____________________

County of ___________________

This document was acknowledged before me on __________(date) by

_____________________________ _____________________________

(name of decision-maker)  (name of supporter)

_____________________________ _____________________________

(signature of notary)  (printed name of notary)

(seal, if any, of notary)

My commission expires: _________________

WARNING: PROTECTION FOR THE DECISION-MAKER WITH A DISABILITY

If a person who receives a copy of this supported decision-making agreement or who is aware of the existence of this agreement has cause to believe that the decision-maker is being abused, neglected or exploited by the supporter, the person shall report the alleged abuse, neglect or exploitation to the department of economic security‘s online reporting system by calling the adult protective services, adult abuse hotline or by calling the local police department.