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e-mail address

OfficeofthePublicGuardianApplication to register a Lasting Power of Attorney

LPA002 Applicationtoregisteralastingpowerofattorney(09.11) ©CrownCopyright2011

Part 1 - The donor

Mr. Mrs. Ms. Miss Other

Return your completed form to:OfficeofthePublicGuardianPOBox16185BirminghamB22WH

Ifother,pleasespecify

Placeacross(x)againstoneoption

Lastname

Firstname

Middlename

Address 1

Address2

Address 3

Town/City

County

Postcode DaytimeTel.no.

D D M M Y Y Y YDateofbirth Iftheexactdateisunknown

pleasestatetheyearofbirth

Pleasedonotwritebelowthisline-Forofficeuseonly

LPA002 09.11

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Part 2 - The persons making the application

Part 3 - How have the attorney(s) been appointed?

Note:Weneedtoknowwhoisapplyingandhowtheattorney(s)havebeenappointed,pleaseanswerthequestionsinpartstwoandthreecarefully.

Thereisonlyoneattorneyappointed

Thereareattorneysappointedjointlyandseverally

Thereareattorneysappointedjointly

Thereareattorneysappointedjointlyinsomemattersandjointlyandseverallyinothers

Placeacross(x)againstoneoption

TheLPAstateswhethertheattorneyistoactsolely,jointlyorjointlyandseverally

IsthedonorapplyingtoregistertheLastingPowerofAttorney? Yes

Istheattorney(s)applyingtoregistertheLastingPowerofAttorney? Yes

Placeacross(x)againstoneoption

Note:Weneedtoknowwhich,ifanyoftheattorney(s)aremakingthisapplicationtoregistertheLPA.Youcantellusthisbyputtingacrossintheboxatthestartofeachattorney(s)detailsinPart4.

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e-mail address

Mr. Mrs. Ms. Miss Other

Ifother,pleasespecify

Placeacross(x)againstoneoption

Lastname

Firstname

Middlename

Address 1

Address2

Address 3

Town/City

County

Postcode

DaytimeTel.no.

D D M M Y Y Y YDateofbirth

Part 4 - Attorney onePlaceacross(x)inthisboxifattorneyoneisapplyingtoregister

Companyname (if relevant)

DX Exchange

DX number

Occupation

Civilpartner/Spouse Child Solicitor Other Otherprofessional

Placeacross(x)againstoneoptionthatbestdescribesyourrelationshiptothedonor

If‘Other’or‘Otherprofessional’,pleasespecify

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e-mail address

Mr. Mrs. Ms. Miss Other

Ifother,pleasespecify

Placeacross(x)againstoneoption

Lastname

Firstname

Middlename

Address 1

Address2

Address 3

Town/City

County

Postcode

DaytimeTel.no.

D D M M Y Y Y YDateofbirth

Part 4 - Attorney twoPlaceacross(x)inthisboxifattorneytwoisapplyingtoregister

DX number

Occupation

Civilpartner/Spouse Child Solicitor Other Otherprofessional

Placeacross(x)againstoneoptionthatbestdescribesyourrelationshiptothedonor

If‘Other’or‘Otherprofessional’,pleasespecify

DX Exchange

Companyname (if relevant)

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e-mail address

Mr. Mrs. Ms. Miss Other

Ifother,pleasespecify

Placeacross(x)againstoneoption

Lastname

Firstname

Middlename

Address 1

Address2

Address 3

Town/City

County

Postcode

DaytimeTel.no.

D D M M Y Y Y YDateofbirth

Part 4 - Attorney threePlaceacross(x)inthisboxifattorneythreeisapplyingtoregister

DX number

Occupation

Civilpartner/Spouse Child Solicitor Other Otherprofessional

Placeacross(x)againstoneoptionthatbestdescribesyourrelationshiptothedonor

If‘Other’or‘Otherprofessional’,pleasespecify

DX Exchange

Companyname (if relevant)

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e-mail address

Mr. Mrs. Ms. Miss Other

Ifother,pleasespecify

Placeacross(x)againstoneoption

Lastname

Firstname

Middlename

Address 1

Address2

Address 3

Town/City

County

Postcode

DaytimeTel.no.

D D M M Y Y Y YDateofbirth

Part 4 - Attorney fourPlaceacross(x)inthisboxifattorneyfourisapplyingtoregister

DX number

Occupation

Civilpartner/Spouse Child Solicitor Other Otherprofessional

Placeacross(x)againstoneoptionthatbestdescribesyourrelationshiptothedonor

If‘Other’or‘Otherprofessional’,pleasespecify

Ifthereareadditionalattorneys,pleaseprovidethefollowingdetailsinthe‘Additionalinformation’sectionattheendofthisform.

DX Exchange

Companyname (if relevant)

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Part 5 - Notification of people to be told

Thedonororattorney(s)makingtheapplicationmustgivenoticetothepeopletobetoldnominatedbythedonorinthesectionoftheLPAmarkedAboutpeopletobetoldwhentheapplicationtoregisterthislastingpowerofattorneyismade.Thedateonwhichthenoticewasgivenmust becompleted(whichisthedateitwaspostedorgiventothepersontobetold).Ifthedonordecidednottonotifyanypeopletobetold,pleaseplaceacrossintheboxprovided.

Lastname

Firstname

Address 1

Address2

Address 3

Town/City

County

Postcode

D D M M Y Y Y Y

Datenoticegiven

ThedonordidnotspecifyanypeopletobetoldintheLPA

I We

havegivennoticetoregisterintheprescribedform(LP001)tothefollowingperson(s):

Placeacross(x)againstoneoption

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Lastname

Firstname

Address 1

Address2

Address 3

Town/City

County

Postcode

D D M M Y Y Y Y

Datenoticegiven

Lastname

Firstname

Address 1

Address2

Address 3

Town/City

County

Postcode

D D M M Y Y Y Y

Datenoticegiven

Part 5 - continued

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Lastname

Firstname

Address 1

Address2

Address 3

Town/City

County

Postcode

D D M M Y Y Y Y

Datenoticegiven

Lastname

Firstname

Address 1

Address2

Address 3

Town/City

County

Postcode

D D M M Y Y Y Y

Datenoticegiven

Part 5 - continued

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Part 6 - FeesGuidelinesonfeeexemptionandremissioncanbeobtainedfromtheOfficeofthePublicGuardian.

Doyouwishtopaythefeebycreditordebitcard? Yes No

Haveyouenclosedachequefortheapplicationtoregisterfee? Yes No

Doyouwishtoapplyforexemptionofthefee? Yes No

Doyouwishtoapplyforremissionofthefee? Yes No

Ifyouwishtopaybycreditordebitcard,pleaseprovideyourtelephonenumbersoanagentcancallyoutoarrangepaymentwhenyourapplicationhasbeenreceived.Ifyouwishtoapplyforanexemptionorremissionofallorpartofthefee,youmustcompletetheseparateapplicationformavailablefromtheOfficeofthePublicGuardian.

Part 7 - Type of power

I We

applytoregistertheLPA(theoriginalofwhichaccompaniesthisapplication)madebythedonorundertheprovisionsoftheMentalCapacityAct2005.

WhattypeofLastingPowerofAttorneyareyouapplyingtoregister?

D D M M Y Y Y Y

DatethatthedonorsignedtheLastingPowerofAttorney

Propertyandfinancialaffairs OR Healthandwelfare

Toyourknowledge,hasthedonormadeanyotherEnduringPowersofAttorneyorLastingPowerofAttorney? Yes No

IfYes,pleasegivedetailsbelowincludingregistrationdateifapplicable

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Part 8 - Donor declaration

Note:ThissectionshouldonlybecompletedbythedonoriftheyareapplyingfortheregistrationoftheLastingPowerofAttorney.

IapplytoregistertheLastingPowerofAttorney(theoriginalofwhichaccompaniesthisapplication).

Icertifythattheaboveinformationiscorrectandthattothebestofmyknowledgeandbelief,IhavecompletedtheapplicationinaccordancewiththeprovisionsoftheMentalCapacityAct2005andallstatutoryinstrumentsmadeunderit.

Lastname

Firstname

SignedD D M M Y Y Y Y

Date

Part 9 - Attorney(s) declarationNote:Thissectionshouldonlybecompletedbytheattorney(s)iftheyareapplyingfortheregistrationoftheLastingPowerofAttorney.

I We applytoregistertheLastingPowerofAttorney(theoriginalof whichaccompaniesthisapplication).

I We certifythattheaboveinformationiscorrecttothebest ofmyknowledgeandbelief.

I We havecompletedtheapplicationwithintheprovisionsofthe MentalCapacityAct2005andallstatutoryinstrumentsmade underit.

Lastname

SignedD D M M Y Y Y Y

Date

Firstname

Lastname

SignedD D M M Y Y Y Y

Date

Firstname

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Part 9 - continued

Lastname

SignedD D M M Y Y Y Y

Date

Firstname

Lastname

SignedD D M M Y Y Y Y

Date

Firstname

Lastname

SignedD D M M Y Y Y Y

Date

Firstname

Part 10 - Declaration by a trust corporationIfyouareatrustcorporationmakingthisapplicationpleasecompletethisdeclaration.

I We

certifythattheaboveinformationiscorrectandthattothebestofmyknowledgeandbelief,IhavecompletedtheapplicationinaccordancewiththeprovisionsoftheMentalCapacityAct2005andallstatutoryinstrumentsmadeunderit.

Lastname

Signatureofauthorisedperson(s)

Firstname

Companyseal(Ifapplicable)

Companyname

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e-mail address

Mr. Mrs. Ms. Miss Other

Ifother,pleasespecify

Placeacross(x)againstoneoption

Lastname

Firstname

Middlename

Address 1

Address2

Address 3

Town/City

County

Postcode

DaytimeTel.no.

Part 11 - Correspondence address

Companyname

DX number

Companyreference

DX Exchange

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Part 12 - Additional informationPleasewritedownanyadditionalinformationtosupportthisapplicationinthespacebelow.Ifnecessaryattachadditionalsheets.