10 | 4 | | AN ACT |
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11 | 5 | | relating to the execution of a declaration for mental health |
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12 | 6 | | treatment. |
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13 | 7 | | BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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14 | 8 | | SECTION 1. The heading to Section 137.003, Civil Practice |
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15 | 9 | | and Remedies Code, is amended to read as follows: |
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16 | 10 | | Sec. 137.003. EXECUTION AND WITNESSES; EXECUTION AND |
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17 | 11 | | ACKNOWLEDGMENT BEFORE NOTARY PUBLIC. |
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18 | 12 | | SECTION 2. Section 137.003(a), Civil Practice and Remedies |
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19 | 13 | | Code, is amended to read as follows: |
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20 | 14 | | (a) A declaration for mental health treatment must be: |
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21 | 15 | | (1) signed by the principal in the presence of two or |
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22 | 16 | | more subscribing witnesses; or |
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23 | 17 | | (2) signed by the principal and acknowledged before a |
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24 | 18 | | notary public. |
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25 | 19 | | SECTION 3. Section 137.011, Civil Practice and Remedies |
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26 | 20 | | Code, is amended to read as follows: |
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27 | 21 | | Sec. 137.011. FORM OF DECLARATION FOR MENTAL HEALTH |
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28 | 22 | | TREATMENT. The declaration for mental health treatment must be in |
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29 | 23 | | substantially the following form: |
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30 | 24 | | DECLARATION FOR MENTAL HEALTH TREATMENT |
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31 | 25 | | I, __________________, being an adult of sound mind, wilfully |
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32 | 26 | | and voluntarily make this declaration for mental health treatment |
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33 | 27 | | to be followed if it is determined by a court that my ability to |
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34 | 28 | | understand the nature and consequences of a proposed treatment, |
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35 | 29 | | including the benefits, risks, and alternatives to the proposed |
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36 | 30 | | treatment, is impaired to such an extent that I lack the capacity to |
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37 | 31 | | make mental health treatment decisions. "Mental health treatment" |
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38 | 32 | | means electroconvulsive or other convulsive treatment, treatment |
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39 | 33 | | of mental illness with psychoactive medication, and preferences |
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40 | 34 | | regarding emergency mental health treatment. |
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41 | 35 | | (OPTIONAL PARAGRAPH) I understand that I may become |
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42 | 36 | | incapable of giving or withholding informed consent for mental |
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43 | 37 | | health treatment due to the symptoms of a diagnosed mental |
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44 | 38 | | disorder. These symptoms may include: |
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45 | 39 | | ________________________________________________________________ |
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46 | 40 | | PSYCHOACTIVE MEDICATIONS |
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47 | 41 | | If I become incapable of giving or withholding informed |
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48 | 42 | | consent for mental health treatment, my wishes regarding |
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49 | 43 | | psychoactive medications are as follows: |
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50 | 44 | | _____ I consent to the administration of the following |
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51 | 45 | | medications: |
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52 | 46 | | ________________________________________________________________ |
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53 | 47 | | _____ I do not consent to the administration of the following |
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54 | 48 | | medications: |
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55 | 49 | | ________________________________________________________________ |
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56 | 50 | | _____ I consent to the administration of a federal Food and |
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57 | 51 | | Drug Administration approved medication that was only approved and |
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58 | 52 | | in existence after my declaration and that is considered in the same |
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59 | 53 | | class of psychoactive medications as stated below: |
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60 | 54 | | ________________________________________________________________ |
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61 | 55 | | Conditions or limitations: ________________________________ |
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62 | 56 | | CONVULSIVE TREATMENT |
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63 | 57 | | If I become incapable of giving or withholding informed |
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64 | 58 | | consent for mental health treatment, my wishes regarding convulsive |
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65 | 59 | | treatment are as follows: |
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66 | 60 | | _____ I consent to the administration of convulsive |
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67 | 61 | | treatment. |
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68 | 62 | | _____ I do not consent to the administration of convulsive |
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69 | 63 | | treatment. |
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70 | 64 | | Conditions or limitations: ________________________________ |
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71 | 65 | | PREFERENCES FOR EMERGENCY TREATMENT |
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72 | 66 | | In an emergency, I prefer the following treatment FIRST |
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73 | 67 | | (circle one) Restraint/Seclusion/Medication. |
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74 | 68 | | In an emergency, I prefer the following treatment SECOND |
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75 | 69 | | (circle one) Restraint/Seclusion/Medication. |
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76 | 70 | | In an emergency, I prefer the following treatment THIRD |
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77 | 71 | | (circle one) Restraint/Seclusion/Medication. |
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78 | 72 | | ______ I prefer a male/female to administer restraint, |
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79 | 73 | | seclusion, and/or medications. |
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80 | 74 | | Options for treatment prior to use of restraint, seclusion, |
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81 | 75 | | and/or medications: |
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82 | 76 | | ________________________________________________________________ |
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83 | 77 | | Conditions or limitations: ________________________________ |
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84 | 78 | | ADDITIONAL PREFERENCES OR INSTRUCTIONS |
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85 | 79 | | ________________________________________________________________ |
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86 | 80 | | Conditions or limitations: ________________________________ |
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87 | 81 | | Signature of Principal/Date: ______________________________ |
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88 | 82 | | SIGNATURE ACKNOWLEDGED BEFORE NOTARY PUBLIC |
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89 | 83 | | State of Texas |
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90 | 84 | | County of_________ |
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91 | 85 | | This instrument was acknowledged before me on ______(date) by |
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92 | 86 | | ___________(name of notary public). |
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93 | 87 | | _____________________ |
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94 | 88 | | NOTARY PUBLIC, State of Texas |
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95 | 89 | | Printed name of Notary Public: |
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96 | 90 | | _____________________________ |
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97 | 91 | | My commission expires: |
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98 | 92 | | _____________________________ |
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99 | 93 | | SIGNATURE IN PRESENCE OF TWO WITNESSES |
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100 | 94 | | STATEMENT OF WITNESSES |
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101 | 95 | | I declare under penalty of perjury that the principal's name |
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102 | 96 | | has been represented to me by the principal, that the principal |
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103 | 97 | | signed or acknowledged this declaration in my presence, that I |
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104 | 98 | | believe the principal to be of sound mind, that the principal has |
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105 | 99 | | affirmed that the principal is aware of the nature of the document |
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106 | 100 | | and is signing it voluntarily and free from duress, that the |
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107 | 101 | | principal requested that I serve as witness to the principal's |
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108 | 102 | | execution of this document, and that I am not a provider of health |
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109 | 103 | | or residential care to the principal, an employee of a provider of |
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110 | 104 | | health or residential care to the principal, an operator of a |
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111 | 105 | | community health care facility providing care to the principal, or |
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112 | 106 | | an employee of an operator of a community health care facility |
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113 | 107 | | providing care to the principal. |
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114 | 108 | | I declare that I am not related to the principal by blood, |
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115 | 109 | | marriage, or adoption and that to the best of my knowledge I am not |
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116 | 110 | | entitled to and do not have a claim against any part of the estate of |
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117 | 111 | | the principal on the death of the principal under a will or by |
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118 | 112 | | operation of law. |
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119 | 113 | | Witness |
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120 | 114 | | Signature: ______________________________________________ |
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121 | 115 | | Print |
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122 | 116 | | Name: _____________________________________________________ |
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123 | 117 | | Date: ______________________ |
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124 | 118 | | Address: _______________________________________________________ |
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125 | 119 | | Witness |
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126 | 120 | | Signature: ______________________________________________ |
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127 | 121 | | Print |
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128 | 122 | | Name: _____________________________________________________ |
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129 | 123 | | Date: ______________________ |
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130 | 124 | | Address: _______________________________________________________ |
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131 | 125 | | NOTICE TO PERSON MAKING A DECLARATION FOR MENTAL HEALTH TREATMENT |
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132 | 126 | | This is an important legal document. It creates a |
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133 | 127 | | declaration for mental health treatment. Before signing this |
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134 | 128 | | document, you should know these important facts: |
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135 | 129 | | This document allows you to make decisions in advance about |
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136 | 130 | | mental health treatment and specifically three types of mental |
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137 | 131 | | health treatment: psychoactive medication, convulsive therapy, |
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138 | 132 | | and emergency mental health treatment. The instructions that you |
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139 | 133 | | include in this declaration will be followed only if a court |
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140 | 134 | | believes that you are incapacitated to make treatment decisions. |
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141 | 135 | | Otherwise, you will be considered able to give or withhold consent |
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142 | 136 | | for the treatments. |
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143 | 137 | | This document will continue in effect for a period of three |
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144 | 138 | | years unless you become incapacitated to participate in mental |
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145 | 139 | | health treatment decisions. If this occurs, the directive will |
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146 | 140 | | continue in effect until you are no longer incapacitated. |
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147 | 141 | | You have the right to revoke this document in whole or in part |
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148 | 142 | | at any time you have not been determined to be incapacitated. YOU |
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149 | 143 | | MAY NOT REVOKE THIS DECLARATION WHEN YOU ARE CONSIDERED BY A COURT |
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150 | 144 | | TO BE INCAPACITATED. A revocation is effective when it is |
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151 | 145 | | communicated to your attending physician or other health care |
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152 | 146 | | provider. |
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153 | 147 | | If there is anything in this document that you do not |
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154 | 148 | | understand, you should ask a lawyer to explain it to you. This |
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155 | 149 | | declaration is not valid unless it is either acknowledged before a |
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156 | 150 | | notary public or signed by two qualified witnesses who are |
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157 | 151 | | personally known to you and who are present when you sign or |
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158 | 152 | | acknowledge your signature. |
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159 | 153 | | SECTION 4. The changes in law made by this Act to Sections |
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160 | 154 | | 137.003 and 137.011, Civil Practice and Remedies Code, apply to a |
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161 | 155 | | declaration for mental health treatment executed on or after the |
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162 | 156 | | effective date of this Act. A declaration for mental health |
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163 | 157 | | treatment executed before the effective date of this Act is |
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164 | 158 | | governed by the law as it existed on the date the declaration for |
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165 | 159 | | mental health treatment was executed, and the former law is |
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166 | 160 | | continued in effect for that purpose. |
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167 | 161 | | SECTION 5. This Act takes effect September 1, 2017. |
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