Lasting Power of Attorney: Questionnaire

Please complete and return this Questionnaire to us before your meeting. Thank you.

Question Title

* 1. Personal information.

Full name

Other names you are known by

Your address, including postcode

Date of birth

Telephone number

Telephone number (mobile)

Email address

Domestic status (e.g single, married, widowed)

Give details of any other Power of Attorney

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* 2. Type of Lasting Power of Attorney (Please indicate which type of Lasting Power of Attorney you wish to make).

Property and Financial Affairs Lasting Power of Attorney

Personal Welfare Lasting Power of Attorney

Both

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* 3. Your Attorneys: We recommend that you appoint at least one but no more than four Attorneys, they do not need to have any specialist skills or experience but it is useful to bear in mind the following guidance (Please tick to acknowledge each statement).

They must be over 18 years of age.

If you are making an LPA for Property and Financial Affairs then they must not be an undischarged or interim bankrupt person.

They must be trustworthy and be able to make decisions on your behalf.

They should be people with whom you have a settled and easy relationship and, if more than one, who get on with each other, or who are likely to do so.

You can choose to appoint only one Attorney, but it is advisable to appoint more than one to lessen the chance of abuse of the Power and ensure continuity in case she/he cannot act.

They can be family members, friends or your professional adviser, such as your solicitor, and they must agree to be your Attorney and should understand the role they will be fulfilling.

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* 4. Please provide us with your Attorney's details: Attorney 1

Full name

Address

Date of birth

Telephone number

Email address

Relationship to you

Occupation

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* 5. Please provide us with your Attorney's details: Attorney 2

Full name

Address

Date of birth

Telephone number

Email address

Relationship to you

Occupation

Question Title

* 6. Please provide us with your Attorney's details: Attorney 3

Full Name

Address

Date of birth

Telephone number

Email address

Relationship to you

Occupation

Question Title

* 7. Please provide us with your Attorney's details: Attorney 4

Full name

Address

Date of birth

Telephone number

Email address

Relationship to you

Occupation

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* 8. How do you want your Attorney's to operate in their role?

If you have more than one Attorney, then you can decide whether you want them to act together in making every decision (called a joint appointment), or together and independently, so that they can make decisions together and alone (called a joint and several appointment).

Together (jointly)

Together and Independently (joint and several)

Some matters together and some independently

I am only appointing one Attorney

Unsure and would like to discuss further with a Lawyer

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* 9. Replacement Attorneys. You may also choose to appoint a replacement Attorney to act in place of an original appointed Attorney should they be unable to act for you.

If you wish to appoint replacement Attorney's please complete this section.

Full name

Address

Date of birth

Telephone number

Relationship to you

Occupation

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* 10. You must choose in the Personal Welfare Power of Attorney whether you wish your Attorney(s) to be able to give or refuse life-sustaining medical treatment on your behalf.

The decisions that your Attorney(s) may have to make are based on the circumstances at the time and not the treatment. It does NOT authorise euthanasia.

Option A: Giving your Attorney authority to make these decisions

Option B: NOT giving your Attorney such authority

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* 11. In order for an LPA to be valid, you must choose a person to act as your Certificate Provider. A Certificate Provider is an independent person who certifies that you have the necessary capacity to make the documents and that you are not under any influence or pressure.

We are happy to act for you as Certificate Provider, provided we are not appointed as Attorneys. If you wish to appoint someone else, please let us have their full details. They must be either a professional person, e.g your doctor, or a person who has known you for at least two years.

Full name

Address

Telephone number

Knowledge/Skills and Experience

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* 12. Your advisor will discuss the importance of adding guidance to your LPA(s) setting out how you would like your attorney(s) to act. If you have any specific ideas about what you would or would not like your attorney(s) to do, please provide a brief outline here.

Lasting Power of Attorney: Questionnaire

Question Title

* 1. Personal information.

Question Title

* 2. Type of Lasting Power of Attorney (Please indicate which type of Lasting Power of Attorney you wish to make).

Question Title

* 3. Your Attorneys: We recommend that you appoint at least one but no more than four Attorneys, they do not need to have any specialist skills or experience but it is useful to bear in mind the following guidance (Please tick to acknowledge each statement).

Question Title

* 4. Please provide us with your Attorney's details: Attorney 1

Question Title

* 5. Please provide us with your Attorney's details: Attorney 2

Question Title

* 6. Please provide us with your Attorney's details: Attorney 3

Question Title

* 7. Please provide us with your Attorney's details: Attorney 4

Question Title

Question Title

* 9. Replacement Attorneys. You may also choose to appoint a replacement Attorney to act in place of an original appointed Attorney should they be unable to act for you.If you wish to appoint replacement Attorney's please complete this section.

Question Title

Question Title

Question Title

* 12. Your advisor will discuss the importance of adding guidance to your LPA(s) setting out how you would like your attorney(s) to act. If you have any specific ideas about what you would or would not like your attorney(s) to do, please provide a brief outline here.

* 9. Replacement Attorneys. You may also choose to appoint a replacement Attorney to act in place of an original appointed Attorney should they be unable to act for you.

If you wish to appoint replacement Attorney's please complete this section.