Fill - Free fillable 2016 Legal Options Manual Low Vision 0 (Arizona) PDF form

A guide to advise individuals, families and caregivers about

dierent legal options for adults with a disability who need

assistance—all with a goal of preserving as many rights as possible

ird Edition: October 2016 - Not for Individual Sale

Legal Options

Manual

This manual was developed for the

Arizona Developmental Disabilities Planning

Council by the

Arizona Center for Disability Law,

the Native American Disability Law Center and

Leigh Bernstein, Esq.

This is not intended as a substitute

for legal advice.

Federal and state law can change at any time.

Please be sure to check current law for any

changes.

Planning Council

Table of Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Representative Payee . . . . . . . . . . . . . . . . . . . . . . . 3

Authorized Representative in the Vocational Rehabilitation Program 7

Form: Declaration of Authorized Representative for Vocational

Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . 11

Designated Representative in Mental Health Care . . . . . . . . . 13

Form: Declaration of Designated Mental Health Representative . . 15

Special Education Transfer of Parental Rights . . . . . . . . . . . 17

Form: Delegation of Right to Make Educational Decisions . . . . 21

Advanced Directives for Health and Mental Health Care, and Living

Wills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Forms: Health Care Power Of Attorney & Living Will - Separate Section

Durable Power of Attorney . . . . . . . . . . . . . . . . . . . . 26

Conservatorship . . . . . . . . . . . . . . . . . . . . . . . . . 29

Guardianship . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Guardianships in Indian Country . . . . . . . . . . . . . . . . . 45

Trusts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

ABLE Accounts . . . . . . . . . . . . . . . . . . . . . . . . . . 51

Appendix A: List of Public Fiduciaries . . . . . . . . . . . . . . 53

Appendix B: County Resources for Guardianship . . . . . . . . . 54

Appendix C: Additional Resources . . . . . . . . . . . . . . . . 57

his manual is the joint project of Arizona Developmental Disabil-

ities Planning Council, the Arizona Center for Disability Law and

the Native American Disability Law Center. The Council is feder-

ally funded and responsible for assuring that individuals with devel-

opmental disabilities and their families participate in the design of,

and have access to, culturally competent services, supports and other

assistance. The Council also supports opportunities that promote in-

dependence, productivity and inclusion into the community.

The Arizona Center for Disability Law is a non-prot, public interest

law rm providing advocacy, information, referral services, community

legal education and, in selected cases, legal representation to

individuals with disabilities throughout Arizona. Its mission is to ad-

vocate for the legal rights of persons with disabilities to be free from

abuse, neglect and discrimination and to gain access to services, max-

imizing independence and achieving equality. The Center’s vision is a

society that focuses on people’s abilities rather than disabilities.

The Native American Disability Law Center is a non-prot public

interest legal services organization that provides information, referrals,

direct representation, systemic advocacy and community education

services to Native Americans with disabilities. The purpose of the

Native American Disability Law Center is to advocate with a generosity

of spirit to ensure that Native Americans with disabilities have access

to justice and are empowered and equal members of their

communities and nations.

The mission of the Native American Disability Law Center is to

advocate on behalf of Native Americans with disabilities in the Four

Corners area to ensure their rights are enforced, strengthened and

brought in harmony with their communities.

Leigh Bernstein, Esq. provided pro bono legal service to assist in

updating the 2016 version of the Legal Options Manual. Her

contribution is greatly appreciated.

This guide is available in alternative formats upon request. This guide

may be copied and distributed for private use but may not be sold or

distributed for prot.

INTRODUCTION

The purpose of this manual is to advise people with disabilities, their

families and caregivers on dierent options available when an adult

with a disability needs the assistance of someone else in a legally

recognized fashion to help manage one or more facets of his or her

life. This is not intended as a substitute for legal advice. Federal

and state law can change at any time. The publication and

revision dates of the manual is located on the front cover; please

be sure to check current law for any changes.

“I like living on my own, but I have some trouble with

remembering to set aside money for all my bills. I have

my own job and earn my own money, but I could use

some help. How can I give someone the ability to help

me with my ﬁnances without giving away my

independence?”

“I think my daughter can live on her own, but I

worry that she will spend her Social Security check

and won’t have money for her bills. How can I help

her manage her money without taking away her

independence?”

“My son just turned 18 and his school is telling me

that I am no longer invited to his Individualized

Education Plan meeting, but my son still wants me to

make decisions about his special education services.

What can I do?”

“I disagree with the state vocational rehabilitation

agency about my employment goal. I want to appeal

their decision but do not believe I can advocate for

myself during an appeal. Can I have someone help me

in this process?”

Questions like these are commonplace in the lives of people with

disabilities and their families and caregivers. Legal options may range

from a student authorizing someone to make decisions in his or her

Individual Education Plan after the student turns 18 to a full

guardianship, which completely restricts a person’s right to make any

of his or her own personal decisions.

People, whether disabled or not, will make mistakes sometimes. That

is a part of life. The purpose of this manual is not to keep individuals

with disabilities from life experiences by taking away their rights to

make decisions for themselves. Rather, the goal is to recognize the

extent to which a person with a disability requires additional

assistance, with the idea that the least restrictive option that preserves

as many individual rights as appropriate is best.

REPRESENTATIVE PAYEE

“I think my daughter can live on her own, but I

worry that she will spend her Social Security check

and won’t have money for her bills. How can I help

her manage her money without taking away her

independence?”

Who needs a representative payee?

Who can be appointed a representative payee?

A person who is not capable of managing his or her nances and who

only receives Social Security benets (like SSI or SSDI) may benet

from a representative payee to help manage these benets.

IMPORTANT NOTE

If a person only receives income from Social Security and he

or she cannot manage his or her own benets to pay

monthly expenses, but is otherwise able to live

independently in the community, a representative payee

may be the only legal option necessary.

However, if the person has other assets that may need

management, another legal option such as a

conservatorship may be more appropriate.

A representative payee should be someone who can manage the

Social Security income of another person with that person’s best

interest and needs in mind. A representative payee can be a family

member, caretaker or friend. If no such person is able to serve as a

representative payee, a public or nonprot agency may also serve as

an organizational

What does a representative payee do?

A representative payee receives Social Security benets on behalf of

a beneciary for the purpose of managing these benets. Specically,

the representative payee must:

• Use the payments only for the use and benet of the beneciary and

for purposes determined to be in the best interest of the beneciary

(such as payment for rent, medical expenses, food, clothing, and

savings);

• Notify SSA of any event that will aect the amount of benets the

person should receive (such as an inheritance or earnings);

• Submit to SSA, upon request, a written report accounting for the

benets and maintain good records of the moneys spent, saved or

invested for the beneciary;

• Notify SSA of any change in circumstances which would aect the

representative payee’s performance (such as payee’s illness or a

change in relationship to the beneciary).

The SSA also publishes “A Guide for Representative Payees” (Pub No.

05-10076) and “When a Representative Payee Manages Your Money”

(Pub No. 05-10097) available on the Internet at www.ssa.gov/pubs or

by calling toll free at 1-800-772-1213 (voice) or 1-800-325-0778 (TTY).

representative payee. If a person lives in a residential facility, that

entity may be able to serve as a representative payee, or if the home

belongs to the Division of Developmental Disabilities (DDD), the

Arizona DES could be the representative payee. Please note that if

you use one of these services, the Social Security Administration

(“SSA”) may authorize the organization to collect a fee for

managing the person’s Social Security benets.

How is a representative payee appointed?

How is the representative payee terminated or changed?

To apply for appointment as a representative payee, you must

complete Form SSA-11, available at your local SSA oce, or by calling

the numbers listed above. In most cases, the applicant must complete

the form in a face-to-face interview at a local SSA oce. The SSA will

make a decision whether the beneciary can manage his or her own

benets and whether the representative payee applicant is an

appropriate person to handle the beneciary’s money.

In determining whether a person needs a representative payee, SSA

will consider:

• A court determination of incompetency and the need for a guardian;

• Medical evidence of the beneciary’s need for a payee to manage

benets; and

• Statements of friends, relatives and caregivers which contain

information on the beneciary’s ability to handle benets.

The SSA also requires evidence of the applicant’s relationship to the

beneciary and evidence substantiating that the applicant will handle

the funds from SSA in a responsible manner, which benets the Social

Security recipient.

The SSA provides forms to change or terminate a representative pay-

ee appointment. A beneciary may request a change in payee if he or

she feels that person is not expending funds in his or her best interest,

or if the relationship between the parties has changed or someone

else would be a more appropriate representative payee. A beneciary

who is now able to handle his or her own benets may also request

that the representative payee status be terminated. Call your local SSA

oce for more information or visit SSA website, www.ssa.gov/payee/.

What happens if the representative payee becomes

unavailable, unable or unwilling to serve as representative

payee?

If the representative payee is no longer available, able or willing to

serve, the representative payee is obligated to notify the Social

Security Administration.

AUTHORIZED REPRESENTATIVE IN THE VOCATIONAL

REHABILITATION PROGRAM

“I disagree with the state vocational rehabilitation

agency about my employment goal. I want to appeal

the decision but do not feel I can advocate for myself

in an appeal. Can I ask someone to help me in this

process?”

Who needs an authorized representative in the Vocational

Rehabilitation Program?

An authorized representative means an applicant or client gave an-

other individual the authority to make decisions, on behalf of the

client or applicant, about services from the Arizona Rehabilitation

Administration Services (AzRSA). The representative does not have

the authority to go against the decision making authority of the cli-

ent or applicant, only to serve on their behalf. A person or client who

believes that they cannot navigate the Vocational Rehabilitation (VR)

Program on their own to get necessary services may benet from an

authorized representative.

However, clients or applicants who can make their own decisions but

need help during meetings, such as speaking up for themselves, ask-

ing questions, and taking notes may invite a family member or trusted

friend to support them in the VR system. This does not require dele-

gating a representative.

Who can be appointed as an authorized representative?

An authorized representative can be a friend, parent, relative, advo-

cate or other person chosen by the client or client’s guardian.

What does an authorized representative do?

The job of an authorized representative is to assist the client in

protecting his or her rights and voicing his or her service needs. The

authorized representative acts as the client’s representative in the

application process, during the development and implementation of

an Individualized Plan for Employment (IPE), and during any appeal

process.

Once a representative has been designated, the VR program must

notify the representative of all the client’s meetings and include the

designated representative in any meeting where the client or

guardian wants the authorized representative to attend. The

authorized representative must act on behalf of the client or guardian

at such meetings, voicing service concerns or other issues. If a client

and their approved representative have a disagreement on a decision

or course of action, the AzRSA sta will follow the direction or desires

of the client.

How is an authorized representative appointed?

Clients, applicants or their guardians must put in writing that they

would like to designate a representative and provide a form or letter to

the VR counselor. Clients and applicants can designate a

representative at any time. Clients who do not appoint a

representative at the beginning may do so later if they need help for an

appeal. There is an example form designating a VR representative at

the end of this section.

How is an authorized representative terminated or changed?

The client or client’s guardian must inform the VR counselor in writing

that they no longer wish for the authorized representative to be

involved. If the client or guardian would like to change the authorized

representative, a new designation form must be provided to the

agency.

What happens if the authorized representative for Vocational

Rehabilitation becomes unavailable, unable or unwilling to

serve as the representative?

A person who selects an authorized representative for Vocational

Rehabilitation can choose a new representative or revoke the

designation at any time. If the person selected as the representative

becomes unavailable or unwilling to serve, the individual can appoint

someone new.

DECLARATION OF AUTHORIZED REPRESENTATIVE

FOR VOCATIONAL REHABILITATION

I understand that I may delegate an authorized representative to help

me protect my rights and assist me in voicing my service needs.

I further understand the following:

1. AZRSA sta will not accept direction form an authorized

representative that supersedes the direction or approval already given

without a client’s direct consent.

2. If a client and their approved representative have a disagreement

on a decision or course of action, AZRSA sta will follow the direction

or desires of the client.

3. All written documentation and notications which are provided to

clients will also be provided to their authorized representative.

I, , hereby designate the person or

organization named below as my representative in the development

and implementation of my Individualized Plan for Employment and in

any appeals process with the Rehabilitation Services Administration

Vocational Rehabilitation Program. This designation shall remain valid

until such time I revoke it in writing.

My authorized representative is:

Authorized Representative’s Name

Address

City State ZIP Code

Telephone Number

Invoked by my signature this day of ,

Client Signature

DESIGNATED REPRESENTATIVE IN MENTAL HEALTHCARE

“My friend is receiving mental health services through

the state, and she has said that she doesn’t feel that

she can make reasonable decisions about her

treatment and planning. How can I help her?”

Who needs to designate a mental health representative?

Any person who receives public mental health benets from a

Regional Behavioral Health Authority (RBHA) or a RBHA member is

entitled to have a designated mental health representative to

represent the RBHA members’ interests. Any RBHA members who

want representatives to make mental health treatment and planning

decisions can designate a mental health representative at anytime.

Who can serve as a designated mental health

representative?

Any person can serve as a mental health representative. If the RBHA

member has a guardian, that person may be the representative, or the

guardian may appoint someone else. The designated representative

can be a friend, parent, relative, advocate, or other person chosen by

the RBHA member or guardian to assist the client in protecting his or

her rights and voicing his or her service needs.

What does a mental health representative do?

A mental health representative is designated by a RBHA member to

help protect the member’s rights and voice their service needs. The

RBHA must provide the designated representative with written notice

about the date, time, and location of meetings about inpatient treat-

ment, discharge planning, and other service planning. The designated

representative may go to service and discharge planning meetings,

help ll out grievance and appeal forms, and attend meetings, which

are informal conferences and administrative hearings related to the

appeals process.

How is a designated representative appointed?

The RBHA member or his or her guardian must let the RBHA know in

writing who is designated to represent the individual. There is an

example of a form designating a mental health representative at the

end of this section.

How is a designated representative terminated or changed?

The RBHA member or guardian must inform the mental health agency

or provider in writing that the designated representative will no

longer be serving as the designated mental health representative or

that a substitute will replace the former representative.

What happens if the designated mental health representative

becomes unavailable, unable or unwilling to serve as the

representative?

A person who selects a designated mental health representative can

choose a new representative or revoke the designation anytime. If the

person selected as the representative becomes unavailable, unable or

unwilling to serve, the individual can appoint someone new.

DECLARATION OF DESIGNATED

MENTAL HEALTH REPRESENTATIVE

I, , hereby designate the person or

organization named below as my representative in the development

of my Individual Service Plan, and the inpatient and discharge plan,

and in any grievance process, pursuant to A.A.C. R9-21-202(A)(17)(c). This

designation shall remain valid until such time I revoke it in writing.

My designated representative is:

Designated Representative’s Name

Address

City State ZIP Code

Telephone Number

Invoked by my signature this day of ,

Signature

SPECIAL EDUCATION TRANSFER OF PARENTAL RIGHTS

“My son just turned 18 and his school is telling me

that I can no longer make decisions regarding his

Individualized Education Plan meeting, but my son still

wants me to make decisions about his special

education services. What can I do?”

Who could benet from delegating the right to make educational

decisions?

When students become 18 years old, the right to make decision about

their special education services is transferred to them because they

are adults under the law. The exception to this rule is when students

become 18 years old and a court has determined that they need a

guardian because they do not have the capacity to make their own

decisions. When there is no guardianship, high school students

between the ages of 18 and 22 receiving special education services,

but who want their parents to make educational decisions, may

benet from having a representative. The student must be able to give

informed consent for the representative’s involvement. This form isn’t

necessary when the student is under a guardianship.

IMPORTANT NOTE

The Delegation of Right to Make Educational Decisions is

only an option when the student reaching age 18 wants a

designated individual to remain involved and can give

informed consent for this involvement.

This legal option is not a mechanism to force a student who

is age 18 to remain in school or in a particular program if he

or she does not want to participate.

Who can be designated to make educational decisions on

behalf of the student?

A student between the ages of 18 and 22 who is not under

guardianship and wants a designee to help make educational

decisions can designate any person to do so. The designee will be

able to exercise the rights aorded to parents, guardians, and students

under the Individuals with Disabilities Education Act. If a student is

under a guardianship, those rights remain with the guardian even

after the student turns 18.

What does a transfer of educational decision-making rights

do?

When a student with a disability reaches age 18—no longer a minor in

the eyes of the law—all parental rights under special education laws

become the rights of the student, unless he or she is under

guardianship. Transferring these rights to someone else allows

another person to make educational decisions on behalf of the

student.

If a student wants his or her parent or another trusted adult to attend

IEP meetings, take notes, and provide support to help the student to

make his own decisions, he or she may invite the parent to the IEP

meeting. Inviting parents to support students in their decision

making does not require a transfer of educational rights.

How is a special education transfer of rights declaration

made?

A student transferring the right to make educational decisions

completes a form like the one provided at the end of this section,

which should be signed and notarized by both the student and the

student’s choice of representative. The student may also make his or

her intentions known by audio, video, or any other means required

because of the student’s disability. The completed form or other

means of expressed intent should be given to school personnel on the

student’s IEP team.

A Delegation of Right to Make Educational Decisions is only eective

for one year from the date it is signed. It must be renewed in writing

by the student each year if it is to remain in eect. The student may

end the transfer of rights or select a dierent representative at any

time. If, at any time, students wish to make their own educational

decisions with support from a parent or trusted friend, the student

may check “revoke” on the form and give it to the school district and

let the school know he or she is inviting the parent to the IEP

meetings. The transfer also terminates when the student graduates.

What happens if the person chosen to make educational

decisions becomes unavailable, unable or unwilling to serve

as the representative?

If the person selected as the representative becomes unavailable,

unable or unwilling to serve, the student can appoint someone new.

DELEGATION OF THE RIGHT TO MAKE

EDUCATIONAL DECISIONS

I, ___________________________________, am eighteen (18)

years of age or older but under twenty-two (22) years of age and

a pupil who has the right to make educational decisions for myself

under state and federal law. I have not been declared legally

incompetent, and as of the date of the execution of this document,

I hereby delegate my right to give consent and to make decisions

concerning educational matters to __________________, who

will be considered my “parent” for the purposes of 20 United

States Code section 1401 and will exercise all the rights and

responsibilities concerning my education that are conferred on a

parent pursuant to state and federal law.

I understand and give my consent that _____________________

will make all decisions relating to my education on my behalf. I

understand that I am entitled to be present during the

development of any individualized education plan and that any

issues or concerns I may have will be addressed.

This delegation will be in effect for one year from today’s date and

may be renewed only by my written or formal authorization. I

understand that I have the right to terminate this agreement at

any time and resume the right make decisions regarding my

education. I understand that I must notify the school immediately

if I revoke this Delegation of Rights prior to its annual expiration.

(OPTIONAL) - I have received this form and have chosen

NOT to delegate my rights.

(REQUIRED) - I have received this form and have

CHOSEN to delegate my rights to the individual listed

below.

(NEXT PAGE)

Page 1 of 2

Page 2 of 2

Student Name

Subscribed and sworn to before me

in the county of

in the State of Arizona on this

day of , 20 ,

Subscribed and sworn to before me

in the county of

in the State of Arizona on this

day of , 20 ,

“Parent” Representative Name

Student Signature

Notary Public

My Commission Expires:

Notary Public

“Parent” Representative Signature

Date Date

(REQUIRED, WHEN APPLICABLE) - I wish to

TERMINATE the delegation of rights at this time and

assume the right to make my own decisions regarding my

education.

Student Signature

Date

Note: If not by writing, this delegation may be given by audio

or video means, or in an alternative format necessitated by the

pupil’s disability.

ADVANCED DIRECTIVES FOR HEALTH AND

MENTAL HEALTH CARE, AND LIVING WILLS

“I want to make sure that my wishes about my phys-

ical and mental health are honored even if I become

unable to speak for myself in the future. What can I do

to protect my interests?”

Who could benet from designating another person to make

health or mental health care decisions for them in the future?

Any person who is of sound mind (legally competent), and wants to

make sure his or her decisions about health or mental health care

treatment will be honored in the future, could benet from an

advanced health or mental health care directive or a living will

appointing someone to carry out his or her wishes in the event he or

she is unable to do so.

IMPORTANT NOTE

Advanced directives and living wills determine what future

treatment will be, so it is critically important that the person

who is making these future decisions has the capacity now

to understand what the directive means.

Who can be appointed to carry out an advanced health care

directive or living will?

Any person can be appointed to carry out an advanced health or

mental health care directive or living will. Like many of the other

options covered in this manual, the appointee should be someone

who will ensure that the wishes of the individual preparing the

directive or living will are honored.

What does an advanced directive or living will do?

Advanced health care directives and living wills allow people to

appoint someone else to make their health care or mental health care

decisions in the event they become incompetent or unable to give

consent in the future. Advanced directives and living wills allow an

individual’s wishes about health or mental health care to be followed

when he or she becomes unable to express these wishes. For any of

these options to be valid, a person must be able to understand and

consent to the treatment choices he or she is making.

What does a health care advanced directive do?

• Health Care Advanced Directive/Durable Health Care Power

of Attorney: This option allows individuals to choose a represen-

tative to make decisions about health care and basic needs if they

become unable to make or communicate those decisions for them-

selves. The representative who makes the decisions is known as the

“agent” or “representative.” The individual who chooses an agent is

the “principal.” Once appointed, the agent will make and communi-

cate decisions about the principal’s health care or basic needs only

if they become unable to make those decisions for themselves. The

document can provide specic direction to the agent regarding

the principal’s wishes for his or her future health care decisions. The

representative will have the authority to make health care decisions

consistent with the principal’s wishes in the event the person sign-

ing the document becomes incompetent. The principal may revoke

this document in full, and change agents and/or add other agents

at any given time. A sample form from the Attorney General’s Of-

ce website is available at the end of this section.

If a power of attorney becomes unavailable, unwilling or unable to

make decisions, the person who appointed the power of attorney can

appoint a new one. The power of attorney forms included in this

manual provide space for an “alternative representative” to be listed

who can step in as the decision maker when the POA is unavailable,

unwilling, or unable to make the decisions.

How are advanced directives and living wills set up?

An attorney who handles probate law can prepare advanced directive

and living wills. Individuals may prepare their own by using advanced

directive forms available at the end of this section. Additional forms

can be obtained from the Oce of the Attorney General’s website,

www.azag.gov (click on “Life Care Planning” link), or by calling

(602) 542-2123. Powers of Attorney/Advance Directives cannot be

created on behalf of another adult. Only the person who wants to

designate an agent to make decisions on her/his behalf in the future

can execute a power of attorney.

Once you have lled out the form and signed it with a notary, it will

be an eective document. Keep it in a safe place with important legal

documents and consider registering it with the Arizona Advance Di-

rective Registry through the Secretary of State (see Appendix C).

How is an advanced directive terminated or changed?

An advanced directive can be changed or ended at any time—even

when the principal appears to have become unable to make rea-

sonable decisions. A mental health care advanced directive may be

changed or ended at any time—except during times when a court has

found the individual to be incapable. Incapable is dened by law and

the court must use this legal denition.

Office of the Attorney General of Arizona, Mark Brnovich

Life Care Planning Packet: Durable Health Care Power of Attorney

Sec. 3: Page 1 of 25

Updated 06/16

OFFICE OF THE ARIZONA ATTORNEY GENERAL

Mark Brnovich

STATE OF ARIZONA

DURABLE HEALTH CARE POWER OF

ATTORNEY

Instructions and Form

GENERAL INSTRUCTIONS: Use this Durable

Health Care Power of Attorney form if you

want to select a person to make future

health care decisions for you so that if you

become too ill or cannot make those

decisions for yourself the person you

choose and trust can make medical

Office of the Attorney General of Arizona, Mark Brnovich

Life Care Planning Packet: Durable Health Care Power of Attorney

Sec. 3: Page 2 of 25

Updated 06/16

decisions for you. Talk to your family,

friends, and others you trust about your

choices. Also, it is a good idea to talk with

professionals such as your doctor,

clergyperson and a lawyer before you sign

this

form.

Be sure you understand the importance of

this document. If you decide this is the form

you want to use, complete the form. Do not

sign this form until your witness or a Notary

Public is present to witness the signing.

There are further instructions for you about

signing this form on page three.

Office of the Attorney General of Arizona, Mark Brnovich

Life Care Planning Packet: Durable Health Care Power of Attorney

Sec. 3: Page 3 of 25

Updated 06/16

1. Information about me (the Principal):

My Name: _______________________________

My Address: ____________________________

My Age: _____________________________

My Date of Birth:_________________________

My Telephone:___________________________

2. Selection of my health care representative

and alternate (“agent”

“surrogate”)

I choose the following person to act as my

representative to make health care

decisions for me:

Name: _______________________________

Address: _____________________________

Home Phone: _________________________

Work Phone: __________________________

Cell Phone: ___________________________

Office of the Attorney General of Arizona, Mark Brnovich

Life Care Planning Packet: Durable Health Care Power of Attorney

Sec. 3: Page 4 of 25

Updated 06/16

I choose the following person to act as an

alternate representative to make health care

decisions on my behalf if the first

representative is unavailable, unwilling, or

unable to make decisions for me:

Name: _______________________________

Address: _____________________________

Home Phone: _________________________

Work Phone: __________________________

Cell Phone: ___________________________

Office of the Attorney General of Arizona, Mark Brnovich

Life Care Planning Packet: Durable Health Care Power of Attorney

Sec. 3: Page 5 of 25

Updated 06/16

3. I AUTHORIZE if I am unable to make

medical care decisions for myself:

I authorize my health care representative to

make health care decisions for me when I

cannot make or communicate my own

health care decisions due to mental or

physical illness, injury, disability, or

incapacity. I want my representative to

make all such decisions for me except

those decisions that I have expressly

stated in Part 4 below that I do not

authorize him/her to make. If I am able to

communicate in any manner, my

representative should discuss my health

care options with me. My repre

sentative

shoul

d explain to me any choices he or she

made if I am able to understand. I further

Office of the Attorney General of Arizona, Mark Brnovich

Life Care Planning Packet: Durable Health Care Power of Attorney

Sec. 3: Page 6 of 25

Updated 06/16

authorize my representative to have all

access to and copies of my “personal

protected health care information and

medical records”. This appointment is

effective unless and until it is revoked by

me or by an order of a court.

The types of health care decisions I

authorize to be made on my behalf

include but are not limited to the

following:

 To c

onsent or to refuse medical care,

including

diagnostic,

surgical, or

therapeutic procedures;

 To authorize the physicians, nurses,

therapists, and other health care

providers of his/her choice to provide

care for me, and to obligate

Office of the Attorney General of Arizona, Mark Brnovich

Life Care Planning Packet: Durable Health Care Power of Attorney

Sec. 3: Page 7 of 25

Updated 06/16

resources or my estate to

pay

reasonable compensation for these

services;

 To approve or

deny

my admittance to

health care institutions, nursing homes,

assisted living facilities, or other facilities

or programs. By signing this form I

understand that I allow my representative

to make decisions about my mental

health care except that he or she cannot

have me admitted to a structured

treatment setting with 24-hour-a-day

supervision and an intensive treatment

program – called a “level one” behavioral

health facility – using just this grant of

authority;

 To have access to and control over

my medical records and to have the

Office of the Attorney General of Arizona, Mark Brnovich

Life Care Planning Packet: Durable Health Care Power of Attorney

Sec. 3: Page 8 of 25

Updated 06/16

authority

to discuss those records

with health

care

providers.

4. DECISIONS I EXPRESSLY DO NOT

AUTHORIZE

Representative

to make

for

me:

I do not want my representative to

make the following health care

decisions for me (describe or write

in “not applicable”):

5. My specific desires about autopsy:

Office of the Attorney General of Arizona, Mark Brnovich

Life Care Planning Packet: Durable Health Care Power of Attorney

Sec. 3: Page 9 of 25

Updated 06/16

NOTE: Under Arizona law, an autopsy is not

required unless the county medical

examiner, the county attorney, or a superior

court judge orders it to be performed. See

the General Information document for more

information about this topic. Initial or put a

check mark by one of the following choices.

____ Upon my death I DO NOT consent to a

voluntary

autopsy.

____ Upon my death I DO consent to a

voluntary

autopsy.

____ My representative may give or refuse

consent for

autopsy.

6. My specific desires about organ

donation (“anatomical gift”):

Office of the Attorney General of Arizona, Mark Brnovich

Life Care Planning Packet: Durable Health Care Power of Attorney

Sec. 3: Page 10 of 25

Updated 06/16

NOTE: Under Arizona law, you may donate

all or part of your body. If you do not make

a choice, your representative or family can

make the decision when you die. You may

indicate which organs or tissues you want

to donate and

where you want them

donated. Initial or put a check mark by A or

B below. If you select B, continue with

your

choices.

A. ____ I

DO NOT WANT to make an organ

or tissue donation, and I do not want this

donation authorized on my behalf by my

representative or my family.

Office of the Attorney General of Arizona, Mark Brnovich

Life Care Planning Packet: Durable Health Care Power of Attorney

Sec. 3: Page 11 of 25

Updated 06/16

B. ____ I DO WANT to make an organ or

tissue donation when I die. Here are my

directions:

1. What organs/tissues I choose to donate:

(Select A,B, or C below)

a. ____ Whole Body

b. ____ Any needed parts or organs

c. ____ These parts or organs only:

2. What purposes I donate my

organs/tissues for: (Select A, B, C, or D

below)

a. ____ ANY legally authorized purpose

(transplantation, therapy, medical

and dental evaluation, education or

research, and/or advancement of

medical and dental science).

✔

Office of the Attorney General of Arizona, Mark Brnovich

Life Care Planning Packet: Durable Health Care Power of Attorney

Sec. 3: Page 12 of 25

Updated 06/16

b. ____ Transplant or therapeutic

purposes only.

c. ____ Research only.

d. ____ Other:

3. Which organization or person I want my

parts or organs to go to: (Select A, B, or

C below)

A. ____ I have already signed a written

agreement or donor card regarding

organ and tissue donation with the

following individual or institution:

(Name)

Office of the Attorney General of Arizona, Mark Brnovich

Life Care Planning Packet: Durable Health Care Power of Attorney

Sec. 3: Page 13 of 25

Updated 06/16

B. ____ I would like my tissues or

organs to go to the following individual

or institution:

____ I authorize my representative to make this

decision.

7. Funeral & Burial Disposition (Optional):

My agent has authority to carry out all

matters relating to my funeral and burial

disposition wishes in accordance with this

power or attorney, which is effective upon

my death. My wishes are reflected below:

Office of the Attorney General of Arizona, Mark Brnovich

Life Care Planning Packet: Durable Health Care Power of Attorney

Sec. 3: Page 14 of 25

Updated 06/16

NOTE: If you choose whole body donation,

cremation is the only burial disposition

available.

Place your initials by those choices you wish

to select.

____ Upon my death, I direct my body to be

buried. (As opposed to cremated).

____ Upon my death, I direct my body to be

buried in _________________________.

(Optional Directive)

____Upon my death, I direct my body to be

cremated.

____ Upon my death I direct my body to be

cremated with my ashes to be

_________________________. (Optional

Directive)

____ My agent will make all funeral and

Office of the Attorney General of Arizona, Mark Brnovich

Life Care Planning Packet: Durable Health Care Power of Attorney

Sec. 3: Page 15 of 25

Updated 06/16

burial disposition decisions (Optional

Directive)

8. About a Living Will

Note: If you have a Living Will and a

Durable Health Care Power of Attorney, you

must attach the Living Will to this form. A

Living Will form is available on the Attorney

General (AG) website. Initial or put a check

mark by box A or B.

A. ____ I have SIGNED AND ATTACHED a

completed Living Will in addition to this

Durable Health Care Power of Attorney to

state decisions I have made about end of

life health care if I am unable to

communicate or make my own decisions

at that time.

Office of the Attorney General of Arizona, Mark Brnovich

Life Care Planning Packet: Durable Health Care Power of Attorney

Sec. 3: Page 16 of 25

Updated 06/16

B. ____ I have NOT SIGNED a Living Will.

9. About a Prehospital Medical Care Directive

or Do Not Resuscitate Directive:

NOTE: A form for the Prehospital Medical

Care Directive or Do Not Resuscitate Directive

is available on the AG website. Initial or put a

check mark by box A or B.

A. ____ I and my doctor or health care

provider HAVE SIGNED a Prehospital

Medical Care Directive or a Do Not

Resuscitate Directive on Paper with

ORANGE background in the even that 911

of Emergency Medical Technicians or

hospital emergency personnel are called

and my heart or breathing has stopped.

B. ____ I have NOT SIGNED a Prehospital

Medical Care Directive or Do Not

Office of the Attorney General of Arizona, Mark Brnovich

Life Care Planning Packet: Durable Health Care Power of Attorney

Sec. 3: Page 17 of 25

Updated 06/16

Resuscitate Directive.

10. HIPAA Waiver of Confidentiality for my

Agent/Representative

____ (Initial) I intend for my agent to be

treated as I would with respect to my rights

regarding the use and disclosure of my

individually identifiable health information or

medical records. This release authority

applies to information governed by the Health

Insurance Portability and Accountability Act

(HIPAA) of 1996, 42 USC 1320d, 45 CFR 160-

164.

SIGNATURE OR VERIFICATION

A. I am signing this Durable Health Care Power

of Attorney as follows:

My signature:

____________________________________

Date:_____________________________________

Office of the Attorney General of Arizona, Mark Brnovich

Life Care Planning Packet: Durable Health Care Power of Attorney

Sec. 3: Page 18 of 25

Updated 06/16

B. I a

m physically unable to sign this

document, so a witness is verifying my

desires as follows:

Witness Verification: I believe that this

Durable Health Care Power of Attorney

accurately expresses the wishes

communicated to me by the principal of this

document. He/she intends to adopt this

Durable Health Care Power of Attorney at

this time. He/she is physically unable to sign

or mark this document at this time, and I

verify that he/she directly indicated to me

that the Durable Health Care Power of

Attorney expresses his/her wishes and that

he/she intends to adopt the Durable Health

Care Power of Attorney at this time.

Office of the Attorney General of Arizona, Mark Brnovich

Life Care Planning Packet: Durable Health Care Power of Attorney

Sec. 3: Page 19 of 25

Updated 06/16

Witness Name (printed):

___________________________

Signature:

______________________________________

Date:

______________________________________

SIG

NATURE OF WITNESS OR NOTARY PUBLIC:

NOTE: At least one adult witness OR a Notary

Public must witness the signing of this

document and then sign it. The witness or

Notary Public CANNOT be anyone who is: (a)

under the age of 18; (b) related to you by blood,

adoption, or marriage; (c) entitled to any part of

your estate; (d) appointed as your

representative; or (e) involved in providing your

Office of the Attorney General of Arizona, Mark Brnovich

Life Care Planning Packet: Durable Health Care Power of Attorney

Sec. 3: Page 20 of 25

Updated 06/16

health care at the time this form is signed.

A. Witness: I certify that I witnessed the

signing of this document by the Principal.

The person who signed this Durable Health

Care Power of Attorney appeared to be of

sound mind and under no pressure to make

specific choices or sign the document. I

understand the requirements of being a

witness and I confirm the following:

 I am not currently designated to make

medical decisions for this person.

 I am not directly involved in

administering health care to this person.

 I am not entitled to any portion of this

person's estate upon his or her death

under a will or by operation of law.

 I am not related to this person by blood,

marriage or adoption.

Office of the Attorney General of Arizona, Mark Brnovich

Life Care Planning Packet: Durable Health Care Power of Attorney

Sec. 3: Page 21 of 25

Updated 06/16

Witness Name (printed):

______________________________________

Signature:

______________________________________

Date:

______________________________________

Address:

______________________________________

Notary Public (NOTE: If a witness signs your

form, you DO NOT need a notary to sign):

STATE OF ARIZONA ) ss

COUNTY OF ____________________)

The undersigned, being a Notary Public certified

in Arizona, declares that the person making

this Durable Health Care Power of Attorney has

Office of the Attorney General of Arizona, Mark Brnovich

Life Care Planning Packet: Durable Health Care Power of Attorney

Sec. 3: Page 22 of 25

Updated 06/16

dated and signed or marked it in my presence

and appears to me to be of sound mind and free

from duress. I further declare I am not related to

the person signing above by blood, marriage or

adoption, or a person designated to make

medical decisions on his/her behalf. I am not

directly involved in providing health care to the

person signing. I am not entitled to any part of

his/her estate under a will now existing or by

operation of law. In the event the person

acknowledging this Durable Health Care Power

of Attorney is physically unable to sign or mark

this document, I verify that he/she directly

indicated to me that this Durable Health Care

Power of Attorney expresses his/her wishes and

that he/she intends to adopt the Durable Health

Care Power of Attorney at this time.

WITNESS MY HAND AND SEAL this ____ day of

Office of the Attorney General of Arizona, Mark Brnovich

Life Care Planning Packet: Durable Health Care Power of Attorney

Sec. 3: Page 23 of 25

Updated 06/16

____________, 20____

Notary Public _____________________________

My Commission Expires: ___________________

Office of the Attorney General of Arizona, Mark Brnovich

Life Care Planning Packet: Durable Health Care Power of Attorney

Sec. 3: Page 24 of 25

Updated 06/16

OPTIONAL:

STATEMENT THAT YOU HAVE DISCUSSED

YOUR

HEALTH CARE CHOICES FOR THE FUTURE

WITH YOUR PHYSICIAN

NOTE: Before deciding what health care you

want for yourself, you may wish to ask your

physician questions regarding treatment

alternatives. This statement from your physician

is not required by Arizona law. If you do speak

with your physician, it is a good idea to have him

or her complete this section. Ask your doctor to

keep a copy of this form with your medical

records.

On this date I reviewed this document with the

Principal and discussed any questions regarding

the probable medical consequences of the

treatment choices provided above. I agree to

Office of the Attorney General of Arizona, Mark Brnovich

Life Care Planning Packet: Durable Health Care Power of Attorney

Sec. 3: Page 25 of 25

Updated 06/16

comply with the provisions of this directive, and

I will comply with the health care decisions made

by the representative unless a decision violates

my conscience. In such case I will promptly

disclose my unwillingness to comply and will

transfer or try to transfer patient care to another

provider who is willing to act in accordance with

the representative's direction.

Doctor Name (printed):

_________________________________

Signature:

__________________________________________

Date:

__________________________________________

Address:

__________________________________________

Office of the Attorney General of Arizona, Mark Brnovich

Life Care Planning Packet: Durable Mental Health Care Power of Attorney

Sec. 4: Page 1 of 17

Updated 06/16

OFFICE OF THE ARIZONA ATTORNEY GENERAL

Mark Brnovich

STA

TE OF ARIZONA

DURABLE MENTAL HEALTH CARE POWER OF

ATTORNEY

Instructions and Form

GENERAL INSTRUCTIONS: Use this

Durable Mental Health Care Power of

Attorney form if you want to appoint a

person to make future mental health care

decisions for you if you become incapable

of making those decisions for yourself.

Office of the Attorney General of Arizona, Mark Brnovich

Life Care Planning Packet: Durable Mental Health Care Power of Attorney

Sec. 4: Page 2 of 17

Updated 06/16

The decision about whether you are

incapable can only be made by a

specialist in neurology or an Arizona

licensed psychiatrist or psychologist who

will evaluate whether you can give

informed consent. Be sure you understand

the importance of this document. Talk to

your family members, friends, and others

you trust about your choices. Also, it is a

good idea to talk with professionals such

as your doctor, clergyperson, and a lawyer

before you sign this form. If you decide

this is the form you want to use, complete

the form. Do not sign this form until your

witness or a Notary Public is present to

witness the signing. There are more

instructions about signing this form on

page 3.

Office of the Attorney General of Arizona, Mark Brnovich

Life Care Planning Packet: Durable Mental Health Care Power of Attorney

Sec. 4: Page 3 of 17

Updated 06/16

1. Inform

ation about me: (I am called the

“Principal”)

My Name:

_________________________________

My Address:

________________________________

My Age:

___________________________________

My Date of Birth:

____________________________

My Telephone:

______________________________

Office of the Attorney General of Arizona, Mark Brnovich

Life Care Planning Packet: Durable Mental Health Care Power of Attorney

Sec. 4: Page 4 of 17

Updated 06/16

2. Selection of my health care representative

and alternate: (Also called an "agent" or

"surrogate")

I choose the following person to act as my

representative to make mental health care

decisions for me:

Name:

______________________________________

Address:

_____________________________________

Home Phone:

_________________________________

Work Phone:

__________________________________

Cell Phone:

___________________________________

Office of the Attorney General of Arizona, Mark Brnovich

Life Care Planning Packet: Durable Mental Health Care Power of Attorney

Sec. 4: Page 5 of 17

Updated 06/16

I choose the following person to act as an

alternate representative to make mental

health care decisions for me if my first

representative is unavailable, unwilling, or

unable to make decisions for me:

Name:

______________________________________

Address:

_____________________________________

Home Phone:

_________________________________

Work Phone:

__________________________________

Cell Phone:

___________________________________

Office of the Attorney General of Arizona, Mark Brnovich

Life Care Planning Packet: Durable Mental Health Care Power of Attorney

Sec. 4: Page 6 of 17

Updated 06/16

3. Mental health treatments that I

AUTHORIZE if I am unable to make decisions

for myself:

Here are t

he mental health treatments I

authorize my mental health care

representative to make on my behalf if I

become incapable of making my own

mental health care decisions due to mental

or physical illness, injury, disability, or

incapacity. If my wishes are not clear from

this Durable Mental Health Care Power of

Attorney or are not otherwise known to my

representative, my representative will, in

good faith, act in accordance with my

best interests. This appointment is

effective unless and until it is revoked by

or by an

order of a court. My

Office of the Attorney General of Arizona, Mark Brnovich

Life Care Planning Packet: Durable Mental Health Care Power of Attorney

Sec. 4: Page 7 of 17

Updated 06/16

representative is authorized to do the

following which I have initialed or marked:

DURABLE MENTAL HEALTH CARE POWER OF

ATTORNEY (Cont’d)

A. ____ A

bout my records: To receive

information regarding mental health

treatment that is proposed for me and to

receive, review, and consent to disclosure of

any of my medical records related to that

treatment.

B. ____ About medications: To consent to

the administration of any medications

recommended by my treating physician.

C. ____ About a structured treatment setting:

To admit me to a structured treatment setting

with 24hour-a-day supervision and an

intensive treatment program licensed by the

Office of the Attorney General of Arizona, Mark Brnovich

Life Care Planning Packet: Durable Mental Health Care Power of Attorney

Sec. 4: Page 8 of 17

Updated 06/16

Department of Health Services, which is

called an inpatient psychiatric facility.

D. ____ Other:

4. Durable Mental health treatments that I

expressly DO NOT AUTHORIZE if I am unable

to make decisions for myself: (Explain or

write in "None”)

5. Revocability of this Durable Mental Health

Care Power of Attorney: This mental health

care power of attorney or any portion of it

may not be revoked and any designated

agent may not be disqualified by me during

times that I am found to be unable to give

informed consent. However, at all other

Office of the Attorney General of Arizona, Mark Brnovich

Life Care Planning Packet: Durable Mental Health Care Power of Attorney

Sec. 4: Page 9 of 17

Updated 06/16

times I retain the right to revoke all or any

portion of this mental health care power of

attorney or to disqualify any agent

designated by me in this document.

6. Additional information about my mental

health care treatment needs (consider

including mental or physical health history,

dietary requirements, religious concerns,

people to notify and any other matters that

you feel are important):

Office of the Attorney General of Arizona, Mark Brnovich

Life Care Planning Packet: Durable Mental Health Care Power of Attorney

Sec. 4: Page 10 of 17

Updated 06/16

HIPAA WAIVER OF CONFIDENTIALITY FOR MY

AGENT/REPRESENTATIVE

____ (Initial) I intend for my agent to be treated

as I would be with respect to my rights regarding

the use and disclosure of my individually

identifiable health information or other medical

records. This release authority applies to any

information governed by the Health Insurance

Portability and Accountability Act of 1996 (aka

HIPAA), 42 USC 1320d and 45 CFR 160-164.

SIGNATURE OR VERIFICATION

A. I am signing this Durable Mental Health Care

Power of Attorney as follows:

My Signature:

______________________________________

Date:

________________________________________

Office of the Attorney General of Arizona, Mark Brnovich

Life Care Planning Packet: Durable Mental Health Care Power of Attorney

Sec. 4: Page 11 of 17

Updated 06/16

DURABLE MENTAL HEALTH CARE POWER OF

ATTORNEY

B. I am physically unable to sign this

document, so a witness is verifying my

desires as follows:

Witness Verification: I believe that this

Durable Mental Health Care Power of

Attorney accurately expresses the wishes

communicated to me by the Principal of this

document. He/she intends to adopt this

Durable Mental Health Care Power of

Attorney at this time. He/she is physically

unable to sign or mark this document at this

time. I verify that he/she directly indicated to

me that the Durable Mental Health Care

Power of Attorney expresses his/her wishes

and that he/she intends to adopt the Durable

Mental Health Care Power of Attorney at this

Office of the Attorney General of Arizona, Mark Brnovich

Life Care Planning Packet: Durable Mental Health Care Power of Attorney

Sec. 4: Page 12 of 17

Updated 06/16

time.

Witness Name (printed):

___________________________

Signature:

______________________________________

Date:

______________________________________

SIGNATURE OF WITNESS OR NOTARY PUBLIC

NOTE: At least one adult witness OR a Notary

Public must witness the signing of this

document and then sign it. The witness or

Notary Public CANNOT be anyone who is: (a)

under the age of 18; (b) related to you by blood,

adoption, or marriage; (c) entitled to any part of

your estate; (d) appointed as your

representative; or (e) involved in providing your

health care at the time this document is signed.

Office of the Attorney General of Arizona, Mark Brnovich

Life Care Planning Packet: Durable Mental Health Care Power of Attorney

Sec. 4: Page 13 of 17

Updated 06/16

A. Witness: I affirm that I personally know the

person signing this Durable Mental Health Care

Power of Attorney and that I witnessed the

person sign or acknowledge the person's

signature on this document in my presence. I

further affirm that he/she appears to be of sound

mind and not under duress, fraud, or undue

influence. He/she is not related to me by blood,

marriage, or adoption and is not a person for

whom I directly provide care in a professional

capacity. I have not been appointed to make

medical decisions on his/her behalf.

Witness Name

(printed):________________________________

Signature:_________________________________

Date:_____________________________________

Office of the Attorney General of Arizona, Mark Brnovich

Life Care Planning Packet: Durable Mental Health Care Power of Attorney

Sec. 4: Page 14 of 17

Updated 06/16

Address:

_________________________________________

B. N

otary Public: (NOTE: If a witness signs your

form, you DO NOT need a notary to sign)

STATE OF ARIZONA ) ss

COUNTY OF ___________________)

The undersigned, being a Notary Public certified

in Arizona, declares that the person making this

Durable Mental Health Care Power of Attorney

has dated and signed or marked it in my

presence and appears to me to be of sound mind

and free from duress. I further declare I am not

related to the person signing above, by blood,

marriage or adoption, or a person designated to

make medical decisions on his/her behalf. I am

not directly involved in providing care as a

professional to the person signing. I am not

Office of the Attorney General of Arizona, Mark Brnovich

Life Care Planning Packet: Durable Mental Health Care Power of Attorney

Sec. 4: Page 15 of 17

Updated 06/16

entitled to any part of his/her estate under a will

now existing or by operation of law. In the event

the person acknowledging this Durable Mental

Health Care Power of Attorney is physically

unable to sign or mark this document, I verify

that he/she directly indicated to me that the

Durable Mental Health Care Power of Attorney

expresses his/her wishes and that he/she

intends to adopt the Durable Mental Health Care

Power of Attorney at this time

WITNESS MY HAND AND SEAL this ____ day of

___________, 20____

Notary

Public:____________________________________

commission expires:

_______________________________

Office of the Attorney General of Arizona, Mark Brnovich

Life Care Planning Packet: Durable Mental Health Care Power of Attorney

Sec. 4: Page 16 of 17

Updated 06/16

OPTIONAL: REPRESENTATIVE’S ACCEPTANCE

OF APPOINTMENT

I accept this appointment and agree to serve as

agent to make mental health treatment decisions

for the Principal. I understand that I must act

consistently with the wishes of the person I

represent as expressed in this Durable Mental

Health Care Power of Attorney or, if not

expressed, as otherwise known by me. If I do not

know the Principal's wishes, I have a duty to act

in what I, in good faith, believe to be that

person's best interests. I understand that this

document gives me the authority to make

decisions about mental health treatment only

while that person has been determined to be

incapacitated which means under Arizona law

that a specialist in neurology or a licensed

psychiatrist or psychologist has the opinion that

Office of the Attorney General of Arizona, Mark Brnovich

Life Care Planning Packet: Durable Mental Health Care Power of Attorney

Sec. 4: Page 17 of 17

Updated 06/16

the Principal is unable to give informed consent.

Representative Name (printed):

__________________________

Signature:

__________________________________________

Date:

__________________________________________

Section 5: Page 1 of 12

Office of the Attorney General of Arizona, Mark Brnovich

Life Care Planning Packet: Living Will (End of Life Care)

Updated 06/16

OFFICE OF THE ARIZONA ATTORNEY GENERAL

Mark Brnovich

LIV

ING WILL (End of Life Care)

Instructions and Form

GENERAL INSTRUCTIONS: Use this Living Will form to

make decisions now about your medical care if you are

ever in a terminal condition, a persistent vegetative

state or an irreversible coma. You should talk to your

doctor about what these terms mean. The Living Will

states what choices you would have made for yourself if

you were able to communicate. It is your written

directions to your health care representative if you have

Section 5: Page 2 of 12

Office of the Attorney General of Arizona, Mark Brnovich

Life Care Planning Packet: Living Will (End of Life Care)

Updated 06/16

one, your family, your physician, and any other person

who might be in a position to make medical care

decisions for you. Talk to your family members, friends,

and others you trust about your choices. Also, it is a

good idea to talk with professionals such as your

doctor, clergyperson and a lawyer before you complete

and sign this Living Will.

If you decide this is the form you want to use, complete

the form. Do not sign the Living Will until your witness

or a Notary Public is present to watch you sign it. There

are further instructions for you about signing on page 2.

IMPORTANT: If you have a Living Will and a Durable

Health Care Power of Attorney, you must attach the

Living Will to the Durable Health Care Power of

Attorney.

Section 5: Page 3 of 12

Office of the Attorney General of Arizona, Mark Brnovich

Life Care Planning Packet: Living Will (End of Life Care)

Updated 06/16

1. My

Information: (the “Principal”)

Name:_________________________________

Address:_______________________________

Age:__________________________________

Date of Birth:___________________________

Phone:________________________________

2. My decisions about end of life care:

NOTE: Here are some general statements about

choices you have as to health care you want at

the end of your life. They are listed in the order

provided by Arizona law. You can initial any

combination of paragraphs A, B, C, and D. If you

initial Paragraph E, do not initial any other

paragraphs. Read all of the statements carefully

before initialing to indicate your choice. You can

also write your own statement concerning life-

sustaining treatments and other matters relating

Section 5: Page 4 of 12

Office of the Attorney General of Arizona, Mark Brnovich

Life Care Planning Packet: Living Will (End of Life Care)

Updated 06/16

to your health care at Heading 3 of this form.

A. ____ Comfort Care Only: If I have a terminal

condition I do not want my life to be prolonged,

and I do not want life - sustaining treatment,

beyond comfort care, that would serve only to

artificially delay the moment of my death. (NOTE:

“Comfort care” means treatment in an attempt to

protect and enhance the quality of life without

artificially prolonging life.)

B. ____ Specific Limitations on Medical

Treatments I Want: (NOTE: Initial or mark one or

more choices, talk to your doctor about your

choices.) If I have a terminal condition, or am in

an irreversible coma or a persistent vegetative

state that my doctors reasonably believe to be

irreversible or incurable, I do want the medical

treatment necessary to provide care that would

keep me comfortable, but I do not want the

Section 5: Page 5 of 12

Office of the Attorney General of Arizona, Mark Brnovich

Life Care Planning Packet: Living Will (End of Life Care)

Updated 06/16

following:

1.) ____ Cardiopulmonary resuscitation, for

example, the use of drugs, electric shock, and

artificial breathing.

2.) ____ Artificially administered food and

fluids.

3.) ____ To be taken to a hospital if it is at all

avoidable.

STATE OF ARIZONA LIVING WILL (“End of Life

Care”) (Cont’d)

C. ____ Pregnancy: Regardless of any other

directions I have given in this Living Will, if I am

known to be pregnant I do not want life-

sustaining treatment withheld or withdrawn if it

is possible that the embryo/fetus will develop

to the point of live birth with the continued

application of life-sustaining treatment.

Section 5: Page 6 of 12

Office of the Attorney General of Arizona, Mark Brnovich

Life Care Planning Packet: Living Will (End of Life Care)

Updated 06/16

D. ____ Treatment Until My Medical Condition is

Reasonably Known: Regardless of the directions

I have made in this Living Will, I do want the use

of all medical care necessary to treat my

condition until my doctors reasonably conclude

that my condition is terminal or is irreversible

and incurable, or I am in a persistent vegetative

state.

E. ____ Direction to Prolong My Life: I want my

life to be prolonged to the greatest extent

possible.

3. Other Statements Or Wishes I Want Followed

For End of Life Care:

NOTE: You can attach additional provisions or

limitations on medical care that have not been

included in this Living Will form. Initial or put a

check mark by box A or B below. Be sure to

include the attachment if you check B.

Section 5: Page 7 of 12

Office of the Attorney General of Arizona, Mark Brnovich

Life Care Planning Packet: Living Will (End of Life Care)

Updated 06/16

A. ____ I have not attached additional special

provisions or limitations about End of Life Care I

want.

B. ____ I have attached additional special

provisions or limitations about End of Life Care I

want.

SIGNATURE VERIFICATION

A. I am signing this Living Will as follows:

Signature:_________________________________

Date:_____________________________________

B. I am physically unable to sign this Living Will,

so a witness is verifying my desires as follows:

Witness Verification: I believe that this Living

Will accurately expresses the wishes

communicated to me by the principal of this

document. He/she intends to adopt this Living

Will at this time. He/she is physically unable to

Section 5: Page 8 of 12

Office of the Attorney General of Arizona, Mark Brnovich

Life Care Planning Packet: Living Will (End of Life Care)

Updated 06/16

sign or mark this document at this time. I verify

that he/she directly indicated to me that the

Living Will expresses his/her wishes and that

he/she intends to adopt the Living Will at this

time.

Witness Name

(printed):___________________________

Signature:_________________________________

Date:_____________________________________

SIGNATURE OF WITNESS OR NOTARY PUBLIC

NOTE: At least one adult witness OR a Notary

Public must witness you signing this document.

The witness or Notary Public CANNOT be

anyone who is: (a) under the age of 18; (b)

related to you by blood, adoption, or marriage;

appointed as your representative; or (e) involved

in providing your health care at the time this

Section 5: Page 9 of 12

Office of the Attorney General of Arizona, Mark Brnovich

Life Care Planning Packet: Living Will (End of Life Care)

Updated 06/16

document is signed.

Witness: I certify that I witnessed the signing

of this document by the Principal. The person

who signed this Living Will appeared to be of

sound mind and under no pressure to make

specific choices or sign the document. I

understand the requirements of being a witness.

I confirm the following:

 I am not currently designated to make

medical decisions for this person.

 I am not directly involved in administering

health care to this person.

 I am not entitled to any portion of this

person’s estate upon his or her death under

a will or by operation of law.

 I am not related to this person by blood,

marriage, or adoption.

ection 5: Page 10 of 12

Office of the Attorney General of Arizona, Mark Brnovich

Life Care Planning Packet: Living Will (End of Life Care)

Updated 06/16

Witness

Name(printed):_____________________________

Signature:_________________________________

Date:_____________________________________

Address:__________________________________

ection 5: Page 11 of 12

Office of the Attorney General of Arizona, Mark Brnovich

Life Care Planning Packet: Living Will (End of Life Care)

Updated 06/16

STATE OF ARIZONA LIVING WILL (“End of Life

Care”) (Last Page)

B. Notary Public: (NOTE: If a witness signs your

form, you DO NOT need a notary to sign)

STATE OF ARIZONA ) ss

COUNTY OF ___________________)

The undersigned, being a Notary Public certified

in Arizona, declares that the person making this

Living Will has dated and signed or marked it in

my presence and appears to me to be of sound

mind and free from duress. I further declare I am

not related to the person signing above, by

blood, marriage or adoption, or a person

designated to make medical decisions on his/her

behalf. I am not directly involved in providing

care as a professional to the person signing. I

am not entitled to any part of his/her estate

ection 5: Page 12 of 12

Office of the Attorney General of Arizona, Mark Brnovich

Life Care Planning Packet: Living Will (End of Life Care)

Updated 06/16

under a will now existing or by operation of law.

In the event the person acknowledging this

Living Will is physically unable to sign or mark

this document, I verify that he/she directly

indicated to me that the Living Will expresses

his/her wishes and that he/she intends to adopt

the Living Will at this time.

WITNESS MY HAND AND SEAL this ____ day of

____, 20____

Notary Public:

________________________________________

My Commission Expires:

________________________________

Section 7: Page 1 of 5

Office of the Attorney General of Arizona, Mark Brnovich

Life Care Planning Packet: Letter To My Representatives

Updated 06/16

OFFICE OF THE ARIZONA ATTORNEY GENERAL

Mark Brnovich

LETTER TO MY REPRESENTATIVE(S)

About Powers of Attorney Forms and

Responsibilities

To My Representative:

Name:____________________________________

Address:__________________________________

To my Alternate Representative:

Name:____________________________________

Address:

____________________________________

Section 7: Page 2 of 5

Office of the Attorney General of Arizona, Mark Brnovich Life

Care Planning Packet: Letter To My Representatives

Updated 06/16

A. What I Ask You to Do for Me: Arizona law

allows me to make certain medical and financial

decisions as to what I want in the future if I

become unable or incapable of making certain

decisions for myself. I have completed the

following document(s), and I want you to be my

representative or alternate representative for the

following purposes. (Initial or check one or more

of the following):

1. ____ Durable Health Care Power of

Attorney

2. ____ Durable Mental Health Care Power of

Attorney

B. Why I Named an Alternate Representative: I

chose two representatives in case one of you is

unable to act for me when the time arises. I ask

that you accept my selection of you as my

representative or alternate. If you do not return

Section 7: Page 3 of 5

Office of the Attorney General of Arizona, Mark Brnovich Life

Care Planning Packet: Letter To My Representatives

Updated 06/16

the Power of Attorney form(s) and this letter to

me or inform me differently, I will assume that

you have agreed to be my representative.

C. Your Responsibilities as My Representative:

By selecting you, I want you to make some very

important decisions for me about my future

health care needs if I become unable to make

these decisions for myself. I might need you to

carry out my medical choices as indicated in the

enclosed Powers of Attorney, even if you do not

agree with them. Please read the copies of the

Powers of Attorney I am giving you. You will be

my voice and will make medical decisions on my

behalf. Other than what I have indicated in the

Powers of Attorney as to my specific directions

on certain issues, I am trusting your judgment to

make decisions that you believe to be in my best

interests. If at any time you do not feel that you

Section 7: Page 4 of 5

Office of the Attorney General of Arizona, Mark Brnovich Life

Care Planning Packet: Letter To My Representatives

Updated 06/16

can undertake this responsibility for any reason,

please let me know. If you are unsure about any

of my directions, please discuss them with me. If

you are not willing to serve as my representative,

please tell me so I can choose someone else to

help me.

As to Health Care: You are not financially

responsible for paying my health care costs

merely by accepting this responsibility. Under

Arizona law, you are not liable for complying

with my decisions as stated in the Powers of

Attorney or in making other health care

decisions for me if you act in good faith.

D. What Else You Should Do: Please keep a copy

of my Powers of Attorney and other documents

in a safe place. Please read these documents

carefully and discuss my choices with me at any

Section 7: Page 5 of 5

Office of the Attorney General of Arizona, Mark Brnovich Life

Care Planning Packet: Letter To My Representatives

Updated 06/16

time. I will give copies of my health care Powers

of Attorney to my physician, and I will give

copies of any or all of these Powers of Attorney

to my family and any other representative I may

choose. I authorize you to discuss with them the

Powers of Attorney, including, as applicable, my

medical situation, or any medical concerns

about me. Please work with them and help them

to act in accordance with my desires and in my

best interests. I appreciate your support, and I

thank you for your willingness to help me in this

way.

Signature:

__________________________________________

Printed Name:

________________________________________

Date:

__________________________________________

Section 7: Page 1 of 6

Office of the Attorney General of Arizona, Mark Brnovich Life

Care Planning Packet: Prehospital Medical Care Directive

Updated 06/16

PREHOSPITAL MEDICAL CARE DIRECTIVE (DO

NOT RESUSCITATE)

(IMPORTANT—THIS DOCUMENT MUST BE ON

PAPER WITH ORANGE BACKGROUND)

GENERAL INFORMATION AND INSTRUCTIONS:

A Prehospital Medical Care Directive is a

document signed by you and your doctor that

informs emergency medical technicians (EMTs)

or hospital emergency personnel not to

resuscitate you. Sometimes this is called a DNR

– Do Not Resuscitate. If you have this form,

EMTs and other emergency personnel will not

use equipment, drugs, or devices to restart your

heart or breathing, but they will not withhold

medical interventions that are necessary to

provide comfort care or to alleviate pain.

IMPORTANT: Under Arizona law a Prehospital

Medical Care Directive or DNR must be on letter

Section 7: Page 2 of 6

Office of the Attorney General of Arizona, Mark Brnovich Life

Care Planning Packet: Prehospital Medical Care Directive

Updated 06/16

sized paper or wallet sized paper on an orange

background to be valid.

You can either attach a picture to this form, or

complete the personal information. You must

also complete the form and sign it in front of a

witness. Your health care provider and your

witness must sign this form.

1. My Directive and My Signature:

In the event of cardiac or respiratory arrest, I

refuse any resuscitation measures including

cardiac compression, endotracheal intubation

and other advanced airway management,

artificial ventilation, defibrillation, administration

of advanced cardiac life support drugs and

related emergency medical procedures.

Section 7: Page 3 of 6

Office of the Attorney General of Arizona, Mark Brnovich Life

Care Planning Packet: Prehospital Medical Care Directive

Updated 06/16

Patient Signature:

_____________________________________

Date:_____________________________________

PROVIDE THE FOLLOWING INFORMATION:

My Date of Birth: _______________

My Sex: ______________________

My Race: _____________________

My Eye Color: _________________

My Hair Color: _________________

ATTACH RECENT PHOTOGRAPH HERE:

Section 7: Page 4 of 6

Office of the Attorney General of Arizona, Mark Brnovich Life

Care Planning Packet: Prehospital Medical Care Directive

Updated 06/16

2. Inform

ation about My Doctor and Hospice (if I

am in Hospice):

Physician:

__________________________________________

Telephone:

__________________________________________

Hospice Program, if applicable (name):

_____________________

ection 7: Page 5 of 6

Office of the Attorney General of Arizona, Mark Brnovich Life

Care Planning Packet: Prehospital Medical Care Directive

Updated 06/16

PREHOSPITAL MEDICAL CARE DIRECTIVE (DO

NOT RESUSCITATE)

3. Signature of Doctor or Other Health Care

Provider:

I have explained this form and its consequences

to the signer and obtained assurance that the

signer understands that death may result from

any refused care listed above.

Signature of a Licensed Health Care Provider:

__________________________________________

Date:

__________________________________________

ection 7: Page 6 of 6

Office of the Attorney General of Arizona, Mark Brnovich

Life Care Planning Packet: Prehospital Medical Care Directive

Updated 06/16

4. Signature of Witness to My Directive:

NOTE: At least one adult witness OR a Notary

Public must witness the signing of this

document. The witness or Notary Public

CANNOT be anyone who is: (a) under the age of

18; (b) related to you by blood, adoption, or

marriage; (c) entitled to any part of your estate;

(d) appointed as your representative; or (e)

involved in providing your health care at the time

this form is signed.

I was present when this form was signed (or

marked). The patient then appeared to be of

sound mind and free from duress.

Signature:

__________________________________________

Date: _____________________________________

DURABLE POWER OF ATTORNEY

I like living on my own, but I have some trouble with

remembering to set aside money for all my bills. I

have my own job and earn my own money, but I could

use some help. How can I give someone the ability

to help me with my ﬁnances without giving away my

independence?”

Who needs a durable power of attorney?

An individual who is of sound mind (legally competent) and who

wants to designate someone else to act as his or her agent, to make

nancial decisions on behalf of the person, or principal, could benet

from a durable power of attorney.

IMPORTANT NOTE

The advantage of this legal option is that it does not require

court intervention and is less expensive and less

complicated than a conservatorship. However, because

there is no court oversight it is extremely important that the

agent be someone who can be trusted to care for the princi-

pal’s needs and to manage the money and assets wisely.

Who may be designated as an “agent” under the durable

power of attorney?

An agent should be someone who can make the important nancial

decisions that the principal gives the agent the authority to make. An

agent could be a spouse, family member, friend, or any other person

who will act in the principal’s best interest.

What does an agent under the durable power of attorney do?

A durable power of attorney document is a document that allows one

person, the principal, to give someone else, the agent, the authority

to handle his or her nancial aairs now, or at some designated time

in the future. For a durable power of attorney to be valid, the principal

who designates the agent must be able to understand and give con-

sent for another person to handle his or her nancial aairs at the time

the power of attorney is signed. The durable power of attorney may

specify what nancial decisions the principal wants the agent to make.

For example, the power of attorney could be limited to paying bills, or

could be permitted to handle all nancial decisions for the principal.

The power of attorney also indicates whether it is eective immediate-

ly or only upon incapacity of the principal.

Unlike a conservatorship, there is no court oversight of a durable pow-

er of attorney. This means the agent does not have to report expendi-

tures to the court on a regular basis. However, an agent may be crim-

inally prosecuted if he or she does not use the money or property for

the benet of the principal.

How is a durable power of attorney made?

A durable power of attorney form must be completed and signed by

the principal, witnessed and notarized. If a power of attorney is only

needed for a person’s nances, the individual’s bank or nancial insti-

tution may have a durable power of attorney form available for clients.

Be sure to check with your bank or nancial institution for specic

requirements for designating a power of attorney to be sure that you

meet the bank requirements. Durable powers of attorney can take

many forms and can cover a variety of legal decision making powers;

it may be worthwhile to consult an attorney to help make sure that

whatever document you use meets all legal requirements for the

purposes you intend.

How is a durable power of attorney changed or ended?

The document that creates a power of attorney may specify when it

ends. The principal may also end the power of attorney by tearing up

the original document or by signing a document that ends it. This

form is called a revocation document. The principal may end the pow-

er of attorney at any time so long as the individual is not incapacitat-

ed. If the principal becomes incapacitated, any interested person who

believes the agent is not acting in the principal’s best interest may

contact the county attorney regarding the matter.

What happens if the person appointed to act as the durable

power of attorney becomes unavailable, unwilling or unable

to serve as the power of attorney?

A person who appoints a durable power of attorney can choose a new

power of attorney or revoke the power of attorney at any time. If a

power of attorney becomes unavailable, unwilling or unable to make

decisions, the person who appointed the power of attorney can ap-

point a new one. Like the durable health care power of attorney and

the durable mental health care power of attorney, a person who ap-

points this power of attorney can also designate an “alternative rep-

resentative” who can step in as the decision maker when the POA is

unavailable, unwilling, or unable to make the decisions. If you want to

be sure that you have a back-up power of attorney, be sure to commu-

nicate that to any lawyer helping you prepare those documents or list

them on any forms you prepare.

CONSERVATORSHIP

“My brother was involved in a car accident and sus-

tained a serious brain injury that resulted in perma-

nent disability. As a result of the accident, he received

a large settlement, but because of his injury, I am con-

cerned that he will not be able to manage this settle-

ment, and I want to make sure that his needs are tak-

en care of. What can I do to help?”

Who needs a conservatorship?

Individuals who are not capable of managing their nances and who

own property or have income or other assets may benet from a

court-appointed conservator. A conservator acts as a person’s nancial

manager, appointed to oversee all the person’s assets and property.

If a person’s only income is from SSI or SSDI, a representative payee

designation may be more appropriate than a conservatorship.

IMPORTANT NOTE

As stated in the introduction, this Manual is not intended as

a substitute for legal advice. The laws regarding conserva-

torships are complex and it is recommended that for ques-

tions about this area of the law, you consult a private attor-

ney.

More than one type of legal decision making authority can

exist at a time. For example, a conservatorship may be ob-

tained at the same time as a guardianship and the same

person could act as both.

Having both a guardian and a conservator is only advised

where the person is deemed incompetent and has

signicant assets.

Who can be appointed as a conservator?

Arizona law requires that a person appointed as a conservator meet

certain standards. The standards include being free of any felony

convictions or other convictions involving theft or other disqualifying

convictions. Individuals to be appointed as conservators must have

completed training required by the Arizona Supreme Court on han-

dling the assets of another.

Arizona law gives priority to the following individuals or agencies when

a conservator is appointed:

1. A conservator, guardian of property or other duciary appointed

or recognized by the appropriate court of any other jurisdiction in

which the protected person resides.

2. An individual or corporation named by the protected person if the

protected person is at least fourteen years of age and has, in the

opinion of the court, sucient mental capacity to make an intelli-

gent choice.

3. The person named to make nancial decisions in the protected per-

son’s most recent durable power of attorney.

4. The spouse of the protected person.

5. An adult child of the protected person.

6. A parent of the protected person or a person named in the parent’s

will, if deceased.

7. Any relative of the protected person with whom the protected per-

son has resided for more than six months before ling paperwork

with the court to ask that a conservator be appointed.

8. The nominee of a person who is caring for or paying benets to the

protected person.

9. The spouse of a veteran or the minor child of a veteran, or the de-

partment of veterans services.

10. A licensed duciary other than a public duciary.

11. A licensed public duciary.

NOTE - Unless the protected person’s money will be in a “restricted” or

“court-controlled” bank account, the conservator must obtain a bond.

A court-controlled bank account is an account set up so that no funds

can be released to anyone without a court order. A bond is like a spe-

cial insurance policy if the conservator stole money or grossly misman-

aged the protected person’s money or property. Often, it is dicult for

family members to obtain the required bond.

What does a conservator do?

A conservator manages the protected person’s money and property.

A conservator must take responsibility for determining what money

and property a protected person has, where the money and property is

located, what measures are needed to preserve certain assets, and how

long these assets can be expected to maintain the protected person.

If the protected person owns a house, the conservator must be certain

that the house is insured and property taxes are current, and that the

protected person is able to aord upkeep on the house. The conserva-

tor pays the protected person’s bills with the protected person’s mon-

ey. The conservator may need to make investment decisions on behalf

of the protected person.

Unless the protected person’s assets are in a “restricted” account, the

conservator must le with the court, as well as share with all interested

persons an accounting that reects all transactions made on behalf of

the protected person. The court accepts accountings only on certain

approved forms, which are available on the probate court’s website for

the county where the conservatorship originated.

How is a conservator appointed?

A petition is led with the court requesting appointment of a conser-

vator. Petition may be led by the person to be protected or an inter-

ested person. Once a hearing is set a notice must be personally served

to the person to be protected of the time and place of the hearing. An

attorney will be appointed to represent the person to be protected,

unless he or she already has one. If the individual to be protected has

a mental illness or disability, the court will appoint an investigator to

interview this person and request appropriate medical or psycholog-

ical evaluations to make sure that a conservatorship is appropriate.

Written reports will be submitted to the court and a hearing will be

held. If the court nds the basis for a conservatorship or any other

protective order has been established, the court will appoint a conser-

vator or enter appropriate protective orders as necessary.

How can a conservatorship be terminated or changed?

Because a conservatorship is a legal relationship, it must be managed

through the court. A petition may be led at any time by the

protected person or other interested parties explaining why a

termination or change in conservator is appropriate.

What are the costs associated with conservatorship?

If the person requesting the conservatorship does not hire an attor-

ney, the only costs are usually the court ling fee (as of October 2016,

the base fee for the state of Arizona is $153, but each county may as-

sign additional fees for ling, which costs $268 in Maricopa County

and $193 in Pima County) and service of process/delivery of the docu-

ments to the person with a disability (between $30–$100 depending

on the location of the potential protected person). There is also an

investigation fee. In Pima County, the fee varies based on the investi-

gator; Maricopa County residents will pay a $400 probate court inves-

tigation fee.

If the court nds that the person to be protected is not in need of

conservatorship, the court can charge the individual bringing the con-

servatorship petition with any costs related to services of a court-ap-

pointed attorney for the person to be protected. Alternatively, if the

court nds the person is in need of conservatorship, the costs associat-

ed with setting up the conservatorship, such as fees for the protected

person’s attorney or other persons appointed by the court to evaluate

the protected person, will come out of the protected person’s money

or a court fund.

Attorney’s fees will vary for performing a conservatorship and may

depend on the nature and complexity of the issues. A conservatorship

requires regular annual accountings to the court. If the accountings

are complex, the assistance of an attorney or accountant may be nec-

essary.

Additionally, Maricopa County charges a fee of $300 for reviewing and

approving the annual accounting.

What happens if the person appointed to act as the

conservator becomes unavailable, unwilling or unable to

serve as conservator?

Because the appointment of a conservator is managed by the court,

only the court can appoint a new conservator to serve in that posi-

tion. When a conservatorship is initially set up, a back-up or alternative

conservator can be requested, but ultimately that decision is up to the

court.

GUARDIANSHIP

“My nephew is an adult with a developmental disabil-

ity. He lives in a group home and does many things

independently, but recently he has been taken advan-

tage of, and he entered into a contract that was not in

his best interest. I am worried that a power of attorney

is not enough to protect him, and I feel helpless. What

else can I do?”

Who needs guardianship?

Individuals who cannot make or communicate reasonable decisions

about their basic needs and care and do not have a decision-maker

appointed through a health care power of attorney who is able and

willing to assist likely need a guardian. Minors who have no parents

or other legal decision makers need a guardian. Adults with devel-

opmental disabilities that prevent them from living without the assis-

tance of another to direct them to dress, eat meals, and walk to the

right bus stop to school, work or day treatment may need a guardian.

Guardians are frequently required for those who have been diagnosed

with dementia, usually in old age, and cannot remember loved ones,

where they live, or how to take their medication.

Who decides whether a guardianship is needed?

When a person turns 18 years old, Arizona law assumes that they may

make their own decisions and do not need a guardian. However, if a

loved one believes that a guardianship is necessary, they may le pa-

perwork called a petition. A petition asks the probate court to deter-

mine whether an individual needs a guardian. In order for a guardian

to be appointed, the court must nd that the person in question lacks

capacity.

The court relies upon the report of a medical examiner and an

investigator who is appointed by the court in reaching its decision. A

person determined to require the assistance of a guardian is called a

“ward.” Legal guardians have legal authority to make decisions for a

client regardless of the client’s wishes. Arizona Rehabilitation Services

(AzRSA) follow directions and decisions provided by a legal guardian

or court-appointed representative over those provided by a client

when the two are in a conict.

The court may appoint a limited guardian or a full guardian. In Arizo-

na, before asking the court to appoint a guardian, individuals must

explore alternatives to a full guardianship for the ward. These alterna-

tives may include one or more of the alternatives listed in this guide,

such as a power of attorney. If appointing a limited guardian is possi-

ble, wards can keep more of their decision-making rights.

• Limited Guardian: A guardian appointed to make decisions about

an individual’s basic care and needs in certain limited areas, such

as health care, where she lives, or the ability to marry. If a guardian

is appointed just to oversee a ward’s medical care, the ward would

still be able to make other decisions without obtaining the guard-

ian’s consent. A person under a limited guardianship may retain the

right to vote and the privilege to drive.

• Full Guardian: A guardian authorized to make all life decisions for

the ward, including making decisions about the individual’s living

arrangements, transportation, education or day programs, social

activities, medical care, and right to marry and association with oth-

ers.

IMPORTANT NOTE

As stated in the introduction, this Manual is not intended as

a substitute for legal advice. The laws regarding

guardianships are complex and it is recommended that for

questions about this area of the law, you consult a private

attorney.

Guardianship requires court intervention, time and

expense, and seriously curtails a person’s independence.

Persons under a full guardianship cannot vote, drive a v

ehicle, or enter into a contract. Under a full guardianship, a

person needs the guardian’s consent to make many

decisions, such as where to live, whether they can marry,

and even when to seek medical help.

Guardianship should only be considered as a last resort

when other legal options such as representative payee,

power of attorney, or conservatorship are not enough to

ensure the person with a disability will be safe and able to

access the services he or she needs.

A guardian must submit an annual written report to the court, includ-

ing information on the ward’s health and living conditions. The guard-

ian must include in this report evidence of the ward’s most recent

contact with a physician within that year at a minimum. Such evidence

might include a copy of a doctor’s notes from a visit or a discharge

summary of the ward if the person has been in the hospital.

Who can be appointed as guardian?

Arizona law requires that a person appointed as a guardian must meet

certain standards. The standards include being free of any felony con-

victions or other convictions, such as theft. The law also requires that,

by the time of appointment, a guardian must have completed a cer-

tain minimum amount of training provided by the Arizona Supreme

Court. The training covers information about looking after another

person.

Arizona law creates a list of individuals or agencies who may be ap-

pointed as guardian:

1. A guardian or conservator of the person or a duciary who is ap-

pointed or recognized by the appropriate court of any jurisdiction

in which the incapacitated person resides.

2. An individual or corporation nominated by the incapacitated per-

son if the person has, in the opinion of the court, sucient mental

capacity to make an intelligent choice.

3. The person nominated to serve as guardian in the incapacitated

person’s most recent durable power of attorney or health care pow-

er of attorney.

4. The spouse of the incapacitated person.

5. An adult child of the incapacitated person.

6. A parent of the incapacitated person, including a person nominat-

ed by will or other writing signed by a deceased parent.

7. Any relative of the incapacitated person with whom the incapaci-

tated person has resided for more than six months before the ling

of the petition.

8. The nominee of a person who is caring for or paying benets to the

incapacitated person.

9. The spouse of a veteran or the minor child of a veteran, or the depart-

ment of veterans services.

10. A licensed duciary other than a public duciary.

11. A licensed public duciary.

Whenever possible, a guardian in Arizona should be someone who

can make important life decisions for a ward using what courts call

substituted judgment. Substituted judgment means that the guard-

ian’s decisions are guided by the wards prior acts, writings, and state-

ments. In other words, exercising substituted judgment means guard-

ians do their best to step into the ward’s shoes and attempt to make

decisions as the ward would.

For example, a guardian is appointed for a young woman with an in-

tellectual disability who has worked at a hotel as a housekeeping as-

sistant for ve years. She loves her job. Her supervisor and co-workers

treat her fairly. She has earned raises each year. Her guardian wants

to place her in a sheltered workshop because he believes she will be

better protected from being red or laid o in the future.

The ward does not want to quit her job and go to a sheltered work-

shop because she likes riding the bus to work and being in the com-

munity. Using substituted judgment, the guardian should permit the

ward to continue working at the resort. She is being treated fairly and

earning more than she could at the workshop. There is no reason to

believe that she is being treated unfairly by her current employer.

If the ward’s preferences cannot be determined, a guardian should be

someone who can make important life decisions for a ward with the

best interests of the ward in mind. Even when using the “best inter-

est” standard, a guardian should strive to maximize the ward’s ability

to make choices whenever possible, and embrace the least restrictive

options in the community for housing, social interaction and employ-

ment.

What does a guardian do?

A guardian has duties and responsibilities similar to what would be ex-

pected of a parent. A guardian oversees a ward’s living situation, med-

ical care, recreation and social outlets in accord with the ward’s wishes

as often as possible. The guardian is responsible for ensuring the ward

lives in the least restrictive appropriate environment.

Does a guardian have authority over those who are in contact

with the ward?

Yes. Beginning December 31, 2016, an Arizona law will go into eect

that spells out the guardian’s authority about with whom wards may

have signicant relationships or contact.

The new law addresses which factors the guardian should consider

when deciding what kind of contact the ward can have with others.

This law also includes how an interested party may go to court to

compel the guardian to allow contact with a ward. The factors spelled

out in this new statute are similar to factors considered in child custo-

dy matters.

When making a decision about the ward’s contact with another indi-

vidual, the guardian must consider, among other factors:

- the wishes of the ward if the ward has sucient mental capacity to

choose

- the mental and physical health of the ward, the person with whom

the ward wishes to have contact

- whether the person with whom contact is requested has committed

an act of domestic violence, child abuse, or abused drugs or alcohol

This new law also requires that within 24 hours of learning of the

ward’s death or hospitalization, a guardian must notify all of the ward’s

family members of the death, including the ward’s spouse, parents,

adult siblings and adult children.

How long does it take for a guardian to be appointed?

Usually a hearing is scheduled within four or ve weeks of ling a

complete petition to appoint a guardian. The guardian will be ap-

pointed at that hearing if all necessary paperwork is submitted, the

medical examiner and investigator support the appointment of a

guardian, and there is no objection.

• A temporary or emergency guardian: A guardian may be ap-

pointed immediately during a hearing scheduled very quickly, with-

out the normal notice period, by a court in certain circumstances

that present harm or imminent harm for the ward. An emergency

guardian may be appointed in as few as 24 hours. An attorney will

be appointed to represent the person for whom guardianship is

being considered. In all but the most dire situations, the court will

require a report from a medical professional (a physician, registered

nurse or psychologist) that describes the medical reason that the

ward is unable to make reasonable decisions for herself. Typically,

a hearing for the appointment of a ‘permanent’ guardian will be

scheduled within 30 to 90 days after the appointment of a tempo-

rary or emergency guardian.

When should a guardian be appointed?

If you are trying to determine whether a guardianship might be

appropriate for someone you know, think about the following:

- Has the individual demonstrated that he or she makes decisions that

put him/her at imminent risk or harm? Has she/he been harmed by

exercising poor judgment?

- Is the individual being denied health care or other services because

providers are concerned about the individual’s ability to understand

his or her treatment?

- Even after getting advice or help from family members, friends or

caregivers, is the individual unable to make important decisions about

where to live, how to get a job, or other services?

- Have treatment providers suggested that the individual does not

have the capacity to make decisions?

For individuals under 18 whose disabilities are so signicant that they

are unable to make reasonable decisions as they approach age 18

(the age of ‘majority’), a guardianship petition may be led when they

reach 17 years and six months. The petitioner may ask that the

guardianship order take eect on the minor’s eighteenth birthday.

Along with the petition, the petitioner may provide a report of an

evaluation of the minor by a physician, psychologist or registered

nurse that meets the court’s requirements, and if the evaluation was

conducted within six months after the date the petition is led with

the court, the petitioner may ask in the petition that the court accept

this report rather than ordering any additional evaluations.

How is a guardian appointed?

Because a guardianship signicantly reduces a person’s ability to make

decisions for him or herself, the process to appoint a guardian requires

a court determination that clear and convincing evidence shows that

a guardianship relationship is appropriate. Any person may

initiate the appointment of a guardian by ling a petition with the

superior court in the county where the potential ward lives. After re-

ceiving the petition, the court will set a hearing date to make its deter-

mination about the guardianship. Unless the potential ward is already

represented by an attorney, the court will appoint an attorney to rep-

resent the person at the hearing. The court will also appoint a court

investigator to interview the potential ward and guardian, and to visit

the place where the ward is living. In addition, a doctor, psychologist

or registered nurse will be appointed by the court to examine the

ward. These experts will submit written reports to the court, and a

hearing will be conducted to determine whether a

guardianship is appropriate. See Arizona State Legislature’s Home Page

for a list of the guardianship state laws, available at

http://www.azleg.gov/arsDetail/?title=14

How is guardianship terminated or changed?

A change or substitution of guardian requires that a petition be led

by the ward or any person interested in the ward’s welfare, or on the

court’s own initiative, and must be found by the court to be in the

ward’s best interest. An acting guardian can be replaced even if she/he

has done nothing wrong so long as the court deems the change to be

in the ward’s best interest. Just as the court considers input from the

court-appointed investigator when initially appointing a guardian, the

court may ask for the input of an investigator in determining what is in

the ward’s best interest when a change of guardian is sought.

NOTE – The ward or guardian must be careful about asking for a

change of guardian sooner than one year after the ward was found to

be incapacitated. The court prohibits an “early” petition for change of

guardian “unless the court permits it to be made on the basis of ada-

vits there is reason to believe the current guardian will endanger the

ward’s physical, mental or emotional health if not substituted.” See

Arizona State Legislature’s Home Page for a list of the guardianship

state laws, available at http://www.azleg.gov/arsDetail/?title=14

A ward may also petition the court at any time for termination of the

guardianship. A guardian is obligated to promote the least restrictive

alternative for a ward whose capacity has been restored, and should

therefore seek to terminate guardianship if the ward can again make

reasonable

decisions about her/his person. While the guardianship statutes give

little guidance, it is wise to assume the court would require a recent

medical report regarding the ward’s improved ability to make deci-

sions about her or his person before terminating a guardianship.

NOTE – The guardianship statute tells us that “an interested person,

other than the guardian or ward, shall not le a petition for adjudi-

cation that the ward is no longer incapacitated earlier than one year

after the order adjudicating incapacity was entered unless the court

permits it to be made on the basis of adavits that there is reason to

believe that the ward is no longer incapacitated.” See Arizona State

Legislature’s Home Page for a list of the guardianship state laws,

available at http://www.azleg.gov/arsDetail/?title=14

What are the costs associated with guardianship?

If the person requests the guardianship without an attorney, the costs

include the court ling fee (as of Oct. 2016, the base fee for the state of

Arizona is $153, but each county may assign additional fees for ing:

$268 in Maricopa County, and $193 in Pima County) and the service of

delivery of documents to the person who will be under guardianship

(between $30–$100 depending on the protected person’s location).

Maricopa County residents will also pay a $400 probate court investi-

gation fee. If the court nds that the person with a disability is not in

need of a guardian, it may assess the costs of the court-appointed at-

torney for the person with the disability to the individual bringing the

guardianship petition. If the court nds the person is in need of guard-

ianship, the costs associated with the guardianship, such as fees for the

ward’s attorney or other persons appointed by the court to evaluate

the ward, will come out of the ward’s money or a court fund. Attorney’s

fees for performing a guardianship will vary depending on the nature

and complexity of the issues. For example, if the guardianship petition

is contested, a trial may result in considerable cost to all parties. Often,

a less restrictive, less complicated and cheaper option is available.

What if the person who needs a guardianship is not a

U.S. citizen?

Arizona permits a person to become a guardian of a foreign citizen if

the person who requires guardianship is under 21 years old and has

either a temporary visa or is a legal permanent resident of the U.S.

What happens if the person appointed to act as the guardian

becomes unavailable, unwilling or unable to serve as guardian?

Because guardianship requires court intervention, only the court

would be able to appoint a new guardian for a person. When a guard-

ianship is initially set up, a back-up or alternative guardian can be re-

quested, but ultimately that decision is up to the court.

GUARDIANSHIP IN INDIAN COUNTRY

“I believe that a guardianship is the most appropriate

legal option for my son, but I live on a reservation.

How do I go about initiating a guardianship that will

be effective on the reservation?”

This section will focus on guardianships only. Most of the other legal

options described in this manual work the same way on tribal lands. If

a less restrictive option is available and appropriate for your situation,

it is worthwhile to consider that rst.

Where do I go to get a guardianship?

In order for a court to issue an enforceable order, it must have jurisdic-

tion or authority over the people involved in the case and the subject

of the case. Typically, when a person lives on a reservation, the tribe’s

courts will have jurisdiction over the issues that arise in that area. Be-

cause of the tribe’s sovereignty, these tribal courts have jurisdiction

over family matters, including guardianships. Even if a state court will

issue an order of guardianship, it may be considered

unenforceable since the state court may not have proper jurisdiction.

IMPORTANT NOTE

It is important to respect the sovereignty of individual

tribal communities. If an individual with a disability lives on

a reservation, the state court does not have jurisdiction and

cannot issue a valid order of guardianship. If a tribe does

not have statute or code, then families should consider the

alternatives outlined in other parts of this manual, such as

representative payee or power of attorney.

How do I get a guardianship in tribal court?

Every tribe in Arizona has sovereign authority over its internal aairs.

The tribe has the authority to make decisions about how its commu-

nity is governed and how it decides the issues facing tribal members.

Arizona has 21 federally recognized tribes and each has its own court

system and laws. How a person obtains a guardianship depends on

where the person lives. Although each tribe may have dierent laws,

there are some common aspects to the guardianship process.

Generally, the tribe will require that a petition be led with the court.

The person ling the petition must be a legal adult—at least 18 years

old. Some tribes, like the Fort McDowell Yavapai community, require

that the individual ling the petition be a member of the tribe. Most of

the tribes that have a guardianship code include requirements similar

to those outlined in this manual’s section on guardianship.

Many tribes have similar standards for determining whether an indi-

vidual needs a guardian. Typically, the threshold is whether or not an

individual is unable to care for him or herself and his or her property.

The Fort McDowell Yavapai community also requires a nding that the

individual have an “unsound mind.” The White Mountain Apache Tribe

adds that the individual may also be “likely to be deceived by artful

and designing persons if a guardian were not appointed.” The Colora-

do River Indian Tribe species that the inability to manage property or

care for him or herself is caused “by the reason of inrmities of aging,

developmental disabilities, or other like incapacities.” Because dierent

tribes have written the code in dierent ways, it is important to look at

the specic code governing the specic tribe involved.

Which tribes have guardianship codes?

• Ak-Chin Indian Community

• Colorado River Indian Tribes of the Colorado River Indian Reservation

• Fort McDowell Yavapai Nation

• Havasupai Tribe of the Havasupai Reservation

• Hopi Tribe of Arizona

• Pascua Yaqui Tribe of Arizona

• Fort Yuma Quechan Tribe

• Salt River Pima-Maricopa Indian Community

• Tohono O’odham Nation of Arizona

• White Mountain Apache Tribe of the Fort Apache Reservation

• Navajo Nation

Some tribes have elected to follow state law if they do not have a

tribal law to address a specic issue or if it does not conict with any

other tribal law.

• Fort Mojave Indian Tribe

• Gila River Indian Community

• Hualapai Indian Tribe of the Hualapai Indian Tribe Reservation

• Yavapai Prescott Tribe of the Yavapai Reservation

Although the tribe allows the use of the state law, the tribal court still

has jurisdiction. An individual seeking a guardianship in these

communities uses the process outlined in the guardianship section of

this manual, but les the papers in the community’s tribal court.

What resources are available?

If a person lives in a tribal community and is a member of that

community, consult with the local legal services oce or tribal court

to see if they have a copy of the law and any forms that can be used.

The person should also consider the other options outlined in this

manual.

TRUSTS

“Our son loves going to Diamondback games and I

want to make sure that he is always able to attend the

games in the Southwest. If we give the money for the

games and travel directly to our son, he will become

ineligible for his Social Security beneﬁts. Is there any-

thing we can do to protect his beneﬁts and still send

him to see his favorite team?”

Who needs a specialized trust?

A person who wants to maintain nancial eligibility for government

programs such as Social Security and who also has funds available

from some other source may benet from a specialized trust. Because

eligibility for certain government programs depends on a person’s in-

come, a trust allows for certain monies to be set aside for a person, or

the beneciary of the trust, to be used for certain purposes. The mon-

ey that goes into the trust could be from an inheritance, settlement or

money that a beneciary’s friend or family member wants to set aside

on his or her behalf.

IMPORTANT NOTE

As stated in the introduction, this Manual is not intended as

a substitute for legal advice. The laws regarding trusts are

complex and it is recommended that for questions about

this area of the law, you consult a private attorney. Unlike

the other legal options discussed, a trust is not something

that families can create by following instructions in a self-

help manual like this. Establishing a special needs trust re-

quires the expertise of an attorney who specializes in this

area of the law because creating a trust that works for an

individual’s specic circumstances requires a professional

who understands the trust options that are available.

What does a specialized trust do?

A specialized trust includes parameters about what the trust money

can and cannot be spent on. By including these limitations, the trust

allows for the beneciary of the trust to receive disbursements from

the trust for certain purposes without jeopardizing a beneciary’s

eligibility for certain government programs.

How is a special needs trust established?

There are a wide variety of options available for persons who want to

create a trust that preserves a beneciary’s ability to maintain

eligibility for certain programs. It is important to seek the expertise

of a specialized attorney. Along with the Arizona Center for Disability

Law, some of the resources listed in Appendix C may be able to

provide referrals to attorneys who are experienced in preparing this

type of specialized trust.

What is an ABLE account and when can I open one?

The ABLE (Achieving Better Life Experience) Act is federal legislation

that allows persons with disabilities (recognized by age 26) and their

family members to create tax-free savings accounts called ABLE

accounts. The Act came into existence in 2014 and several states

immediately established programs to administer ABLE accounts.

Arizona’s version of the ABLE Act was signed into law in May 2016 and

should become eective no later than July 2017.

ABLE accounts, unlike regular bank accounts, may hold more than

$2,000 and will not disrupt eligibility for public benets for persons

with disabilities. In addition, it appears that ABLE accounts for persons

with disabilities, even those who receive ‘need-based’ benets such as

SSI and ALTCS, may be used for such things as housing, personal

support services, medical care, assistive technology, and

transportation. So ABLE accounts oer greater exibility than Special

Needs Trusts. ABLE accounts should be less expensive to establish and

easier to manage than Special Needs Trusts.

“I would like to save some money for the future, but

I’m afraid to lose my beneﬁts. I can’t hold more than

$2,000 right now without a penalty. What options do I

have?”

ABLE ACCOUNTS

However, ABLE accounts have limitations, particularly for those

catastrophically injured who receive large personal injury settlements

or those who may inherit a large sum. For example, an ABLE account

may be funded at a rate of $14,000 per year. So, one receiving

settlement proceeds or an inheritance in excess of $14,000 will likely

still need to consider creating a Special Needs Trust to hold the excess

funds. Also, persons with disabilities receiving SSI and Medicaid may

have no more than $100,000 in an ABLE account without

experiencing a reduction in the need-based benets received.

In addition, there can be only one ABLE account for any given

individual with a disability. And, as in the case of self-settled special

needs trusts, any ABLE account balance left upon the account

beneciary’s death will likely go the state Medicaid agency—the

Arizona Health Care Cost Containment System in Arizona.

Once ABLE accounts are available in Arizona, persons with disabilities

who receive need-based benets will have a valuable resource never

before available—the ability to have a bank account with a balance

over $2,000 that can be used relatively freely. ABLE accounts are an

important addition to Special Needs Trusts for persons with disabilities

and their families.

An ABLE account may be established for an Arizona resident in

another state so long as that state accepts ‘foreign’ accounts. A

caution: As with many decisions related to how the funds of persons

with disabilities may be used, it is always wise to rst check with

AHCCCS before opening an ABLE account out of state for an Arizona

resident.

APPENDIX A

ARIZONA PUBLIC FIDUCIARIES

Apache County

Patricia Hall

75 W. Cleveland, 2nd

Floor

St. Johns, AZ 85936

(928) 337-7627

Greenlee County

Nora Garza

223 Fifth St.

Clifton, AZ 85533

(928) 865-2323

Pima County

Philip H. Grant

32 N. Stone Ave., 4th

Floor

Tucson, AZ 85701

(520) 724-5454

Cochise County

Vicki Haviland

4 Ledge Ave.

Bisbee, AZ 85603

(520) 432-9660

La Paz County

Vivian Hartless

1105 W. 14th St.

Parker, AZ 85344

(928) 669-6163

Pinal County

Joan Sacramento

971 N. Jason Lopez Cir.

Florence, AZ 85132

(520) 866-7252

Coconino County

J.R. Rittenhouse

2625 N. King St., 2nd Fl.

Flagsta, AZ 86004

(928) 679-7441

Maricopa County

Catherine Robbins

222 N. Central Ave.,

Ste 4100

Phoenix, AZ 85004

(602) 506-5801

Santa Cruz County

Rita Luz Ashford

2150 N. Congress Dr.

Nogales, AZ 85621

(520) 375-7892

Gila County

Tiany Poarch

5515 S. Apache Ave.,

Ste. 800

Globe, AZ 85501

(928) 425-3149

Mohave County

Rashida Suminski

700 W. Beale St.

Kingman, AZ 86402

(928) 718-4959

Yavapai County

Pamela E. Bensmiller

1015 Fair St. Rm.326

Prescott, AZ 86303

(928) 771-3153

Graham County

Sherrie Lines

820 W. Main St.

Saord, AZ 85546

(928) 428-4441

Navajo County

Sherry Reed

100 E. Code Talkers Dr.

Holbrook, AZ 86025

(928) 524-4353

Yuma County

Candy Wheeler-Ruby

3007 S. Pacic Ave.

Yuma, AZ 85365

(928) 373-1145

APPENDIX B

COUNTY RESOURCES FOR GUARDIANSHIP FORM

County What form Where do I nd forms?

is used?

Apache Modied*

Maricopa

County

forms

www.azcourts.gov/selfservicecenter/SelfSer-

viceForms.aspx

www.superiorcourt.maricopa.gov

Apache County Clerk of Court: (928) 337-7550

Cochise Modied*

Maricopa

or other

Arizona

county

forms

www.azcourts.gov/selfservicecenter/SelfSer-

viceForms.aspx

www.superiorcourt.maricopa.gov

Cochise County Clerk of Court: (520) 432-8601

Coconi-

Coconino

County

forms

www.coconino.az.gov

www.azcourts.gov/selfservicecenter/SelfSer-

viceForms.aspx

Coconino County Clerk of Court: (928) 679-

7600

Gila Modied*

Maricopa

County

forms

www.azcourts.gov/selfservicecenter/SelfSer-

viceForms.aspx

Gila County Clerk of Court: (928) 402-8866

Graham Graham

County

forms

www.azcourts.gov/selfservicecenter/SelfSer-

viceForms.aspx

Graham County Clerk of Court: (928) 428-3100

*Modied: If online form allows, replace “Maricopa” or “Pima” with

your county, and modify

otherwise as appropriate. If you are not able to modify form online,

print the form, cross out the county, and write in the proper county

for your document.

County What form Where do I nd forms?

is used?

Greenlee Modied*

Maricopa

or other

Arizona

county

forms,

modied to

“Greenlee

County”

www.azcourts.gov/selfservicecenter/SelfSer-

viceForms.aspx

www.superiorcourt.maricopa.gov

Greenlee County Clerk of Court: (928) 865-

4242

La Paz Modied*

Maricopa

County

forms

www.azcourts.gov/selfservicecenter/SelfSer-

viceForms.aspx

www.superiorcourt.maricopa.gov

La Paz County Clerk of Court: (928) 669-6131

Marico-

Maricopa

County

forms

www.azcourts.gov/selfservicecenter/SelfSer-

viceForms.aspx

www.superiorcourt.maricopa.gov (court

forms)

Maricopa County Clerk of Court: (602) 372-

5375

Maricopa County Bar Association: (602) 257-

4200

Mohave Mohave

County

forms

www.azcourts.gov/selfservicecenter/SelfSer-

viceForms.aspx www.mohavecourts.com

Mohave County Clerk of Court: (928) 753-0713

Forms can also be obtained at your Clerk of Superior Court’s oce, and

may be available at your area’s legal aid oce (CLS, SALA, or

DNA People’s Legal Services). See Resource List for contact information.

County What form Where do I nd forms?

is used?

Navajo Modied*

Pima or

Maricopa

County

forms

www.azcourts.gov/selfservicecenter/SelfSer-

viceForms.aspx

www.superiorcourt.maricopa.gov

Navajo County Clerk of Court: (928) 524-4188

Pima Pima Coun-

ty forms

www.azcourts.gov/selfservicecenter/SelfSer-

viceForms.aspx fhttp://www.sc.pima.gov

Pima County Clerk of Court: (520) 724-3201

Pima County Bar Association: 177 N. Church

Ave., Tucson

(520) 623-8258

Pinal Pinal

County

forms

www.azcourts.gov/selfservicecenter/SelfSer-

viceForms.aspx http://www.coscpinalcoun-

tyaz.gov/forms.html

Pinal County Clerk of Court: (520) 866-5300

Santa

Cruz

Modied*

Pima or

Maricopa

County

forms

www.azcourts.gov/selfservicecenter/SelfSer-

viceForms.aspx

www.superiorcourt.maricopa.gov

Santa Cruz County Clerk of Court: (520) 375-

7700

Yavapai Yavapai

County

forms

http://courts.yavapai.us/selfservicecenter/

Yavapai County Clerk of Court: (928) 771-3312

Verde Valley Oce: (928) 567-7741

Yuma Modied*

Maricopa

County

form

www.azcourts.gov/selfservicecenter/SelfSer-

viceForms.aspx

www.superiorcourt.maricopa.gov

Yuma County Clerk of Court: (928) 817-4222

APPENDIX C

Additional Resources

The following sources may be useful regarding various options covered

in this manual. You may wish to explore these resources for additional in-

formation about your specic needs. This information is current as of the

publication date of this manual. The agencies are listed for information

and reference purposes, and are not specically endorsed by the publish-

ers of this manual.

Resource Website/Contact information

Above and Beyond Representative

Payee Service (Tucson)

Area Agency on Aging (Region 1)

(Phoenix)*

Information and referral services for

issues on guardianship, call Senior HELP

LINE (602) 264-HELP (4357).

Check website for other information

or services available. *Area Agencies

on Aging have oces throughout the

state, as well. Visit the “Disability

Resources” link at www.azdes.gov for

further information on your area’s

oce.

ARC of Arizona

Advocates for the rights and full

community participation for all

individuals with developmental and

intellectual disabilities.

Phone: (520) 903-1733

www.aaaphx.org

Phone: (602) 264-2255

Toll Free: (888) 783-7500

www.arcarizona.org

Phone: (602) 234-2721

arc@arcarizona.org

(voice message system)

Resource Website/Contact information

Arizona Advance Directive Registry

This website, provided by the Arizona

Secretary of State, is designed to

provide information, registration and

free secure storage of a person’s

advance directives, i.e., living will,

medical power of attorney or mental

health power of attorney.

Arizona Attorney General’s Oce

This website provides valuable

information concerning life

planning—explanations, videos, FAQs

and documents that can be viewed,

downloaded, or requested. The forms

are identical to those provided as

examples in this manual.

Ability360 (Phoenix area)

Center focused on programs that

empower individuals with disabilities in

achieving independent living skills. See

website for all services provided.

Arizona Center for Disability Law

Non-prot public interest law rm

and protection and advocacy agency

protecting the rights of persons with

disabilities. Does not provide services

regarding options mentioned in this

manual—information and referral only.

Check website for other services

provided.

www.azsos.gov/services/

advanced-directives

Phone: (602) 542-6187

Toll free: (800) 458-5842

www.azag.gov/seniors/life-

care-planning

Phone: (602) 542-2123

Toll Free: (800) 352-8431

resourcecenter@az.gov

www.ability360.org

Phone: (602) 256-2245

Arizona Relay 711

http://azdisabilitylaw.org

Phone: (602) 274-6287

(Voice/TTY)

Toll Free: (800) 927-2260

(Voice/TTY)

Resource Website/Contact information

Arizona Commission for the Deaf and

Hard of Hearing

Statewide center oering services and

referral information for persons with

hearing loss.

Arizona Department of Economic

Security

Division of Developmental Disabilities

Arizona Department of Veterans’

Services

For information regarding duciary

(conservatorship and guardianship)

services. Phone numbers for other

oces on the website.

Arizona Developmental Disabilities

Planning Council

Provides original research and support

to projects that serve the developmen-

tal disability community in Arizona. See

website for digital version of this Legal

Options Manual.

Arizona Governor’s Council on Spinal

and Head Injuries

Resource for information, services and

support for persons with traumatic

brain or spinal cord injuries, and those

who support them.

www.acdhh.org

Phone: (602) 542-3323

TTY: (602) 364-0990

Toll Free Voice/TTY:

(800) 352-8161

VP - (480) 559-9441

www.azdes.gov/

developmental_ disabilities/

Phone: (602) 542-0419

Toll Free: (866) 229-5553

www.dvs.az.gov

Phone: (602) 627-3261

addpc.az.gov

Phone: (602) 542-8970

Toll Free: (877) 665-3176

www.azheadspine.org

Phone: (602) 774-9148

Resource Website/Contact information

Arizona Judicial Courts

Self-service forms relating to

guardianship or conservatorship are

provided for use in some Arizona

counties listed on this website.

Arizona Secretary of State

Provides secure storage of advance

directives; link to Attorney General’s Life

Planning Documents.

Arizona Senior Citizens Law Project

Oers information and legal assistance

to seniors over 60 in Maricopa County.

AZ Law Help

Website providing a wide array of

information and links, including

resources for nding legal help.

Community Legal Services, Inc.

(Central Phoenix area)

May provide some guardianship

services; must qualify for services. CLS

has multiple oces in Phoenix area and

western counties of Arizona, including

Mohave, Yavapai and Yuma. Check

website for listings, and contact for

information on guardianship.

and information.

www.azcourts.gov/self-

servicecenter/SelfService-

Forms.aspx

Phone: (602) 452-3460

www.azsos.gov

Phone: (602) 542-4285

Phone: (602) 252-6710

www.azlawhelp.org

Maricopa Referral Line:

(602) 257-4434

Pima County Referral Line:

(520) 623-4625

www.clsaz.org

Phone: (602) 258-3434

Toll Free: (800) 852-9075

TTY: (602) 254-9852

infocpo@clsaz.org

Resource Website/Contact information

DNA People’s Legal Services

May provide some guardianship

services; 10 locations serving

both o-reservation and tribal land

communities of Northeastern

Arizona. Low Income—must qualify for

services. See website for oce locations

and information.

Guardianship or Conservatorship

forms, instructions

County Court forms and some

information can be found on your

County Clerk of Court’s website, or at

the Arizona Judicial Branch website.

Not every county has its own form at

this time, but you may modify another

county’s form as needed.You can also

obtain the forms from your local Clerk’s

oce.

Although an attorney is not required

to le for guardianship, it is still a good

idea to consult a professional to ensure

that you are submitting paperwork

appropriate for your needs.

Lawyer Referral Service (Maricopa

County Bar Association)

30 minute consultation for $40;

check website for information

regarding this service.

Lawyer Referral Service (Pima County

Bar Association)

30-minute consultation for $35; and

QUILT program for persons who are low

income, but don’t qualify for legal aid;

check website or call for

information regarding these ser vices.

Guardianship forms available.

www.dnalegalservices.org

Phone: (928) 871-4151

www.azcourts.gov/selfser-

vice center/ SelfService-

Forms.aspx

http://maricopalawyers.org

Phone: (602) 257-4434

www.tucsonlawyers.org

Phone: (520) 623-4625

Resource Website/Contact information

Maricopa County Superior Court,

Clerk’s Oce

Provides general court information,

some self-service forms and ling fee

information. The website provides

phone numbers for specic

departments.

NAELA (National Academy of Elder

Law Attorneys)

Provides general court information,

some self-service forms and ling fee

information. The website provides

phone numbers for specic

departments.

Native American Disability Law

Center

Agency serving and protecting the

legal rights of Native Americans with

disabilities in the four corners area

of Arizona, Colorado, New Mexico and

Utah. Check website for services

provided.

Northern Arizona Council of

Governments (NACOG) — Elder

Rights Unit, Area Agency on Aging

Serving Apache, Coconino, Navajo and

Yavapai Counties, may provide some

information concerning guardianships

or referral to attorneys. Must be 60

years of age.

www.clerkofcourt.maricopa.

gov/

Phone: (602) 372-5375

www.naela.org

Phone: (703) 942-5711

www.nativedisabilitylaw.org

Phone: (800) 862-7271

www.nacog.org

Phone: (928) 774-1895

nacog@nacog.org

Resource Website/Contact information

Pima Council on Aging (PCOA)

(Pima County)

Designated Agency on Aging. No direct

assistance regarding options in this

book, but may provide referrals to

attorneys. Must be age 60 or over.

Pima County Superior Court,

Clerk’s Oce

Provides general court information,

some self-service forms, including

guardianship and conservatorship, and

ling fee information.

Social Security Administration

Check this website for information

about representative payee issues.

Southern Arizona Legal Aid

May provide some assistance with

guardianship; must qualify for services.

SALA has oces serving Apache, Gila

and Navajo Counties, Cochise, Graham/

Greenlee Counties, Pima County,

Pinal County and Santa Cruz County.

Check website for specic oce

locations and numbers, and service

availability.

www.pcoa.org

PCOA HELPLINE:

(520) 790-7262

www.sc.pima.gov

Phone: (520) 724-3200

www.ssa.gov/payee/

Toll Free: (800) 772-1213

TTY: (800) 325-0778

www.sazlegalaid.org

Phone: (520) 620-0443

Toll Free: (800) 640-9465

Applying for New Services:

Phone: (520) 620-0443

Toll Free: (800) 248-6789

Resource Website/Contact information

Special Needs Alliance (SNA)

Website provides information about

special needs trusts, guardianship,

conservatorship, and other associated

issues. Resource for locating attorney

experienced in public entitlements and

special needs planning.

Special Needs Answers

Website provided by Academy of

Special Needs Planners, information

about special needs trusts and related

matters, such as nding an attorney.

State Bar of Arizona

Provides information about nding an

attorney—no direct referrals.

www.specialneedsalliance.

org

Phone: (877) 572-8472

info@specialneedsalliance.

org

www.specialneedsanswers.

com

Phone: (866) 296-5509

www.azbar.org

Phone: (602) 252-4804

Toll Free from outside

Maricopa County:

(866) 482-9227

(602) 542-8970 | Toll Free: (877) 665-3176

addpc.az.gov

3839 N. 3rd Street, Suite 306, Phoenix, AZ 85012

Download
Save PDF to desktop

Email
Email completed PDF

Send for Signing
Email for others to sign

Print
Print document

NAME

2016 Legal Options Manual Low Vision 0 (Arizona)

View Audit Log
Print With Audit Log
Duplicate Document

Fill Online, Printable, Fillable, Blank 2016 Legal Options Manual Low Vision 0 (Arizona) Form

Related forms

Fillable 2016 Legal Options Manual Low Vision 0 (Arizona)

Fill Online, Printable, Fillable, Blank 2016 Legal Options Manual Low Vision 0 (Arizona) Form

Related forms

First 20 documents completely FREE!