Lasting Power of Attorney

Pro Forma

Please complete the following giving as many details as possible. If you have any queries or would like support, please contact our office on 01228 542156.

About You

Please tell us your full name, including any middle names and your title, i.e. Mr David John Smith*
Please tell us your full postal address, including your postcode *
Please tell us your Date of Birth *
Please tell us a telephone and / or mobile number we can use to contact you if we have questions *
Mobile Number
Please tell us an email address we can contact you on *

About Your Attorney(s)

You need to appoint at least one Attorney, but you may choose to appoint more than one.

An Attorney can be a family member, a trusted friend or a professional advisor, provided they:

  • are over the age of 18, fully understand the role and responsibilities and have agreed to act as your Attorney
  • must not be or have been bankrupt
  • must possess appropriate skills to make decisions on your behalf and not lack mental capacity

You Attorney's appointment will be ended if:

  • they refuse to act, they die, become bankrupt or lack capacity to act
  • If they have a marriage or civil partnership with you that is dissolved or annulled

Attorney 1

Please tell us the full name of the first person you wish to name as an attorney *
Please provide their full address, including postcode *
Please tell us their date of birth *
Please tell us their phone number *
Please tell us their relationship to you *
Please tell us their job title *

Attorney 2

If you wish to have more than one attorney

Please tell us the full name of the second person you wish to name as an attorney
Please provide their full address, including postcode
Please tell us their date of birth
Please tell us their phone number
Please tell us their relationship to you
Please tell us their job title

Attorney 3

If you wish to have more than two attorneys

Please tell us the full name of the third person you wish to name as an attorney
Please provide their full address, including postcode
Please tell us their date of birth
Please tell us their phone number
Please tell us their relationship to you
Please tell us their job title

Substitute Attorney

You may choose to appoint someone as a substitute Attorney, who will stand in if an Attorney is no longer able to act on your behalf. If there is no substitute Attorney and your Attorney(s) are no longer able to act, the LPA will no longer be valid.

Please tell us the full name of the person you wish to name as a substitute attorney
Please provide their full address, including postcode
Please tell us their date of birth
Please tell us their relationship to you

Restrictions and Conditions

If you have named more than one Attorney, please tick the correct box to tell us how you want them to be able to act.

Joint Only - must make all decisions and sign all documents together

Joint and Severally - may make decisions together but may also make decisions and sign documents individually

Jointly for some decisions and Jointly and Severally for other decisions - you can specify below which decisions require Attorneys to act jointly and which decisions can be made individually

Joint Decisions:
Individual Decisions:
If you wish to include any legally binding limitations or restrictions to prevent the Attorney(s) from doing certain things, please tell us here, i.e. I do not want my home sold until a doctor says I am not well enough to live alone
If you wish to provide any additional guidance for your Attorneys, that is not legally binding, please tell us here
Please tell us if you would like your Attorney(s) to be paid. Note: Professional Attorneys will expect to be paid for their services. Family and friends may not expect to be paid but you may wish to cover any expenses they incur

Notifying Others - the person(s) to be told

You can choose one or more people to be notified when your LPA is registered, who can raise concerns on your behalf. If you do not choose anyone to be notified, then two certificate providers will be required instead of just one.

The person(s) you choose to notify can be a member of your own family or a close friend, but not an Attorney or someone who lives with an Attorney.

The person(s) simply need to agree that when your LPA is registered they are happy for notice to be sent to them. They are under no obligation to do anything with the notice unless they wish to object to the LPA being registered.

Please tell us the full name of the first or only person you wish notice to be given to
Please provide their full address, including postcode
Please tell us their date of birth
Please tell us their phone number
Please tell us their relationship to you
Please tell us the full name of the second person you wish notice to be given to
Please provide their full address, including postcode
Please tell us their date of birth
Please tell us their phone number
Please tell us their relationship to you

Certificate Provider Details

A certificate provider signs to say that you, the donor, understands what the LPA is, the authority you are giving your Attorneys and are not being pressurised into making the LPA.

For this reason it is important you choose your Certificate Provider(s) carefully to meet the criteria:

  • Have relevant professional skills to make the assessment of you, i.e. a GP or solicitor
  • OR Have known you well for at least two years (more than an acquaintance) and not be related to you or the Attorney(s)

If you have chosen a person(s) to be notified, you need only choose one Certificate Provider, if not you must choose two.

Please tell us the full name of your first or only certificate provider *
Please provide their full address, including postcode *
The full name of your second certificate provider
Please provide their full address, including postcode

Additional Information

Please tell us the details of any previous Lasting or Enduring power of Attorney, including the registration date if applicable
Please tell us any additional information you wish to provide, or comments in response to any of the questions above.

Declaration

  • I confirm that I am over the age of eighteen years and am of sound mind.
  • I certify that the information given in this form is true and complete and correctly represents my wishes and is to be used as a basis for preparing my Lasting Power of Attorney.
  • I understand that on registration there may be a fee payable to the Office of the Public Guardian dependent upon my financial circumstances (£110 maximum as from October 2011)
  • I understand there is a fee payable to Carlisle Carers of £125 to cover the preparation of and registration of the LPA and associated administration costs
  • I understand Carlisle Carers may contact me to confirm my instructions and clarify any further information required.

I agree to the declaration stated above

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