(a) The following individuals, except if the individual is the supported person's relative, may not be a supporter:
(1) An individual who provides physical, mental, or behavioral healthcare services or disability services to the supported person, or the owner or operator of the entity providing the healthcare services or disability services to the supported person; or
(2) An individual who works for a government agency that is financially responsible for the supported person's care.
(b)(1) An individual shall not be a supporter if:
(A) There is or has been a finding by a government agency that the individual:
(i) Abused, neglected, or exploited the supported person; or
(ii) Inflicted harm upon a child, elderly individual, or person with a disability; or
(B) The individual is or has been convicted of any of the following criminal offenses, or their equivalent in any other state or territory, within 7 years before entering the supported decision-making agreement:
(i) Any sexual offense prohibited in subchapter II of Chapter 30 of Title 22 where the victim was a child, elderly individual, or person with a disability;
(ii) Aggravated assault, as described in § 22-404.01, where the victim was a child, elderly individual, or person with a disability;
(iii) Fraud, as described in § 22-3221;
(iv) Theft in the first degree, as that term is used in § 22-3212(a);
(v) Forgery, as described in § 22-3241; or
(vi) Extortion, as described in § 22-3251.
(2) Paragraph (1) of this subsection shall not apply to a covered education agreement.
(c) A supported decision-making agreement must be signed by the adult with a disability and the supporter in the presence of 2 adult witnesses or a notary public.
(d) Except for a covered education agreement, a supported decision-making agreement shall be in substantially the following form:
"SUPPORTED DECISION-MAKING AGREEMENT
"Appointment of Supporter
" I, (name of supported person), make this agreement of my own free will.
" I agree to designate the following person as my supporter:
" Phone Number:
" E-mail Address:
" My supporter may help me with making everyday life decisions relating to the following:
" Y/N applying for and maintaining supports and services including District government assistance
" Y/N obtaining food, clothing, and shelter
" Y/N taking care of my physical health
" Y/N taking care of my mental/behavioral health
" Y/N managing my financial affairs
" Y/N managing real property transactions
" Any other duties as listed below:
" NOTHING IN THIS DOCUMENT GIVES MY SUPPORTER PERMISSION TO MAKE DECISIONS FOR ME.
" Nothing in this document prevents my supporter from also serving as a power of attorney or as a healthcare decision-maker.
" To help me with decisions, my supporter may:
" Y/N Help me obtain information that is relevant to a decision, including medical, psychological, financial, educational, or treatment records;
" Y/N When requested by me, be present to help me make my own decisions;
" Y/N Help me understand my options so that I can make an informed decision; and
" Y/N Help me communicate my decision to appropriate persons.
" Y/N A release allowing my supporter to see and obtain protected health information under the Health Insurance Portability and Accountability Act of 1996 is attached.
" Y/N release allowing my supporter to see and obtain educational records under the Family Educational Rights and Privacy Act of 1974 is attached.
"Effective Date of Supported Decision-Making Agreement
" This supported decision-making agreement is effective immediately and will continue until (insert date) or until the agreement is terminated by my supporter or me or by operation of law.
" Signed this _______day of _________, 20___
"Consent and Attestation of Supporter
" I, (name of supporter), consent to act as a supporter under this agreement and affirm that:
" 1. I have not been found to have abused, neglected, or exploited (name of supported person) by a government agency;
" 2. I have not been found to have inflicted harm upon a child, elderly individual, or person with a disability by a government agency;
" 3. In the last 7 years, I have not been convicted of any sexual offense where the victim was a child, elderly individual, or person with a disability;
" 4. In the last 7 years, I have not be convicted of aggravated assault where the victim was a child, elderly individual, or person with a disability; and
" 5. In the last 7 years, I have not been convicted of fraud, theft in the first degree, forgery, or extortion.
" Signature of Supporter Printed Name of Supporter
"Signature of Supported Person
" I, (name of supported person), consent to have (name of supporter) act as my supporter under this agreement.
" My signature Printed Name of Supported Person
"Signature of Two Witnesses
" Signature of Witness Printed Name of Witness (1)
" Signature of Witness Printed Name of Witness (2)
" This document was acknowledged before me on this ____ day of (insert month and year) by (name of person supported) and (name of supporter).
" Signature of Notary Public and notary seal, if any.
" Printed Name of Notary Public
" My commission expires:
"WARNING: PROTECTION FOR PERSON SUPPORTED
" IF A PERSON WHO RECIVES [RECEIVES] A COPY OF THIS AGREEMENT OR IS AWARE OF THE EXISTENCE OF THIS AGREEMENT HAS CAUSE TO BELIEVE THAT THE ADULT NAMED AS A SUPPORTED PERSON IS BEING ABUSED, NEGLECTED, OR EXPLOITED BY THE SUPPORTER, THE PERSON MAY REPORT THE ALLEGED ABUSE, NEGLECT, OR EXPLOITATION TO THE CITYWIDE CALL CENTER AT 311, METROPOLITAN POLICE DEPARTMENT AT 911, ADULT PROTECTIVE SERVICES AT (202) 541-3950."
(e) A supported decision-making agreement may be terminated at any time by the supported person or the supporter.