SPECIMEN LASTING POWER OF ATTORNEY

Transcription

1 SPECIMEN LASTING POWER OF ATTORNEY PLEASE COMPLETE THIS FORM IN BLOCK CAPITALS. 1. ORDER. I require an LPA for Health & Welfare only OR Property & Affairs only OR Both If you require BOTH types of LPAs, the Attorneys and Certificate Providers MUST be the same for each. If NOT, a separate form needs to be completed for each LPA. I require Mirror LPAs If you require Mirror LPAs and ALL Attorneys, Certificate Providers etc are the SAME, you need only complete ONE application form. 2. Registration with the Office of Public Guardian.(OPG) Do you wish to register your Power with the OPG? (recommended) YES NO If YES- Are you to pay the :- A) Full Fee B) 50% Fee Remission C ) Entitled to Fee Exemption Please note- these fees are chargeable per power. If you qualify for B or C you will need to provide proof of income, please refer to the OPG Fee Guide for a list of acceptable proofs. I have enclosed the following :- Fee Proof of Income To Follow :- Fee Proof of Income 3. Donor Details Title Mr Mrs Miss Ms Other J O H N E D W A R D Any Other Name(s) you are known by in financial documents or Accounts S M I T H 1 4 L O N G L A N E, O A K E S T A T E, O L D L Y, K E N T K E J L Date of Birth Are you able to read? YES x NO Are you able to write? YES x NO 1

2 4. Attorney(s) You must appoint at least ONE Attorney, most people appoint 2 or 3. N.B. The Attorney or replacement Attorney must NOT be an undischarged Bankrupt. Attorney 1. Title Mr Mrs Miss Ms Other M A R Y J A N E S M I T H 1 4 L O N G L A N E, O A K E S T A T E, O L D L Y, K E N T K E J L Date of Birth Are you appointing ONE sole Attorney and NO replacement? YES NO If YES, you need to be aware that, if the sole Attorney were to predecease the Donor, lose mental capacity, or become bankrupt, then the LPA would become obsolete. Please tick to confirm your understanding of the above. Attorney 2. Title Mr Mrs Miss Ms Other A L A N D A V I D S M I T H T H E L E Y S, B R A M B L E L A N E, O L D L Y, K E N T K E 7 8 S T ENGINEER Date of Birth SON Attorney 3 Date of Birth If appointing more than 3 Attorneys please provide details on the continuation sheet. 2

3 5. I wish my Attorney(s) to act: (i) Sole Attorney (ii) Together If you choose option (ii) then any Attorney who is unable to act jointly with the remaining Attorneys due to predeceasing the donor, losing mental capacity etc, will render the LPA INVALID. If a replacement Attorney has been nominated, then the replacement Attorney will take over from ALL remaining joint Attorneys and will act as the Donor s SOLE Attorney. (iii) Together and independently (iv) Together in respect of some matters and together and independently in respect of others). CARE - If you choose option (iv) and the OPG deem it to be unworkable it could render the LPA INVALID and it will be rejected at the OPG Registration process. Together in respect of Independently in respect of 6. Replacement Attorney(s). (Please note that you do NOT have to appoint replacements.) Are you appointing only ONE Replacement Attorney? YES NO If YES, then should this Attorney have to act as an Attorney, they will only be able to act in the same capacity as the Attorney they are to replace. If No, then should the replacement Attorneys have to act as Attorneys, then they will ALL be required to act as Attorneys and you should select from the following: I wish my Replacement Attorneys to act: (i) Together (ii)together and independently (iii)together in respect of some matters and together and independently in respect of others). CARE - If you choose option (iii) and the OPG deem it to be unworkable it could render the LPA INVALID and it will be rejected at the OPG Registration process. Together in respect of- Independently in respect of 3

4 Continued- Replacement Attorneys Replacement Attorney 1. Title Mr Mrs Miss Ms Other J A N E A D E L E M O R R I S 2 6 W E S T C L I F F E R O A D, C H A T H A M, K E N T K E 2 6 L B SOLICITOR NIECE Date of Birth O Replacement Attorney 2. Date of Birth Where appointing more than One Replacement Attorney Is EACH Replacement Attorney to replace a specific Attorney? YES If YES then please name the Attorney to be replaced and by whom. Please list below. Name of Replacement Attorney NO If NO then ALL Replacement Attorneys will be appointed in place of the first Attorney who can no longer act. Name of Attorney to be replaced: Name of Replacement Attorney Name of Attorney to be replaced: 4

5 7. Restrictions You Do Not have to set any restrictions, but if you do so, then, they are legally binding. Care If the OPG deem the restrictions to be unworkable it could render the LPA invalid. I wish to place restrictions and/or conditions on my Attorney(s) in relation to my Power for : Personal Welfare YES NO Property & Financial Affairs YES NO Restrictions and/or conditions on the Powers of your Attorney(s) - please provide full details below. 8.Guidance You Do Not have to state any guidance, but if you do so then they are NOT legally binding. Care If the OPG deem the guidance to be unworkable it could render the LPA invalid. My Attorney(s) should consider the following guidance when making decisions in my best interest. NONE 2

6 9. Notifying others (People to be told) You must name a minimum of 1 person and a maximum of 5 people who you wish to be notified when an application to register your LPA is made - these cannot be your Attorney(s). However, if you do not name anyone you must provide details of TWO Certificate Providers. 3

7 10.Certificate Providers You MUST choose 1 Certificate Provider (2 if you have NO notified person) Your Certificate Provider must be someone you have either known personally for over 2 years or, someone who is able to provide a Certificate, because of their professional skills or expertise. NB: You cannot choose someone from your own immediate family or related to you by marriage, a business partner or paid employee of yours or your Attorney(s), an Attorney appointed on this form or another LPA or an existing EPA, the owner, director, manager or an employee of a care home in which you live, or their family. Certificate Provider 1. Title Mr Mrs Miss Ms Other F R A N K E D W A R D B A R N E S 1 6 L O N G L A N E, O A K E S T A T E, O L D L Y, Category of Certificate Provider. K E N T K E 7 8 S T Known for over 2 years? YES FRIEND You MUST give details of how they are known to you (ie friend) OR Skills Certification (for professions such as GP, Magistrate, Accountant- please refer to LPA Guide) Relevant Professional skills: Certificate Provider 2. Title Mr Mrs Miss Ms Other B E T H A N Y L O U I S E R O B E R T S B E E C H C O T T A G E, A S H F O R D, K E N T, K E L L Category of Certificate Provider. Known for over 2 years? YES You MUST give details of how they are known to you (ie friend) FRIEND 4

8 OR Skills Certification. (for professions such as GP, Magistrate, Accountant- please refer to LPA Guide) Relevant Professional skills: Declaration to be signed by all clients The information recorded in this form is my/our instruction/s and I/we know of no reason why my/our Lasting Power Of Attorney(s) should not be prepared in this way. On this basis I/we instruct Countrywide Legal Services Ltd to supply the documents in this order. I/We understand that the documents prepared will not be legally valid until they are signed correctly and I/we undertake to sign all completed documents with suitable witnesses according to the printed instructions which will be returned with my/our documents. I confirm that the Cancellation process has been fully explained to me/us and that I/we have been issued with the following forms: Notice of my Right to Cancel Request for work to start (if applicable) Cancellation Form Date Client A Signature Client B Signature In order for us to produce your documentation to a high standard, the information contained within this Instruction Sheet must be accurately recorded. In particular, we would ask that you read and confirm the names, addresses and relationships of ALL parties to your Lasting Power of Attorney to ensure that they are correct. I / we confirm that, the names, addresses and relationships of all the parties to be mentioned in my/our Lasting Power of Attorney(s) have been recorded accurately. Name of of Adviser. JAMES MASSEY Adviser Contact Number

9 Countrywide Tax & Trust Corporation Abbotsfield House, 43 High Street, Kenilworth, Warwickshire. CV8 1RU 6