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Enduring Power of Attorney
As principal, you complete this form by writing on the line and ticking the appropriate boxes.
1. I, ______________________ [Name] of _________________________ [Address] appoint _________________________ [Lawyer] of _________________________ [Address] Phone: (---) ________________, as my lawyer, under this enduring power, for
(check one box only):
[ ] financial matters
[ ] personal/health matters
[ ] financial and personal/health matters.
2. Do you want to set any terms for the power given in clause 1 (eg. limit the power of your attorney or give specific information about your wishes)?
[ ] No. Go to 4.
[ ] Yes.
3. Write these terms here: (For example: ‘I would prefer that my lawyer does not sell my share in XYZ Limited or "If I need nursing-home care, I want my attorney to try XYZ Nursing Home first".
Do not include any instructions in this document about withdrawing or withholding life-sustaining medical treatment. You can only give such instruction in an Advance Health Directive.)
4. Have you given your lawyer power to make decisions about financial matters?
[ ] No. Go to 6.
[ ] Yes.
5. When do you want the power of your lawyer/s for financial matters to begin? (check one box only).
[ ] Immediately.
[ ] On this date:
Date when you want the power of your lawyer to begin ___/___/___.
[ ] On this occasion:
Write here the occasion when you want the power of your lawyer to begin ___/___/___. If you do not complete this clause the power begins immediately.
6. Are you appointing more than one lawyer?
[ ] No. Go to 8.
[ ] Yes.
7. How do you prefer that they make their decision? (check one box only)
[ ] Severally (any one of them may decide)
[ ] Jointly (Unanimously)
[ ] As a majority (if you are appointing more than one lawyer, please specify, eg. "Simple majority’", "Two-thirds majority")
[ ] Other (specify, eg. "Successively in the order named") _____________________.
8. STATEMENT OF UNDERSTANDING
(1) I fully understand that, by signing this document, I give power to the attorney/s mentioned in clause 1 to make decisions on my behalf about matters mentioned in the same clause.
(2) I understand that I may specify or limit the lawyers power, and instruct the attorney/s about the exercise of the power.
(3) I understand that this gives the lawyer/s power to do, or me, anything I could lawfully do myself in relation to these matters (except for special personal/health matters), subject to any terms mentioned in this form.
(4) I understand that:
(a) the power of attorney for financial matters (if applicable) begins at the time stated in Clause 5 and continues even if I lose capacity;
(b) the power of attorney for personal/health matters (if applicable) begins only if/when I lose capacity.
(5) I understand that I may change or revoke this enduring power of attorney at any time so long as my power to make such a decision is not impaired, in other words, so long as I am capable of making another enduring power of attorney.
(Your signature here)
I, _______________________________, state that:
(Person signing for the principal prints his/he full name here)
(a) I am at least eighteen years old
(b) I am not a witness for this directive or a lawyer for the principal.
(Person signing for the principal)
(Witness signs here)
PART 2: For the witness
Your role goes beyond ensuring that the signature of the principal (the person giving the power) is genuine. You certify that the principal appeared to understand the nature and effect of the document, including the matters stated in clause 8 (Statement of understanding). In the future, you may have to provide information about the principal/s capacity to understand these matters when giving the power. If you are doubtful about the principal’s capacity, you should make appropriate inquiries, eg. from the principal’s doctor.
It is strongly recommended that, if you are in any doubt, you make a written record of
As lawyer, you complete the section of this form that applies to you by writing on the lines and ticking the boxes. If you are not able to tick all the boxes truthfully, then you must not accept this appointment as lawyer.
(Lawyer completes this section)
10. I, ________________________ [Name] state that:
[ ] I am eighteen or over,
[ ] I am not a current paid carer of the principal,
[ ] I am not a current health-care provider for the principal,
[ ] I have read Part 1, giving me enduring power of attorney,
[ ] I understand that, by signing this document, I take on the responsibility of exercising the power I have been given in the document,
[ ] I also understand that I must exercise the power in accordance with the Powers of Attorney Act 1998.
(Your signature here)