Ariz. Rev. Stat. § 14-5722
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:
Revocation or Termination of Agreement
Important Information for Supporters About
the Limits to this Agreement
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 section 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.
A.R.S. § 14-5722