Lpa117 Form – Fill Out and Use This PDF

Information you must read !

This lasting power of attorney is a legal document.

Each person who signs parts A, B and C must read this information before signing.

Purpose of this lasting power of attorney

This lasting power of attorney gives your attorneys authority to

make decisions about your property and inancial affairs when you

cannot make your own decisions. This can include running your bank accounts and savings accounts, decisions about making or selling investments and selling property, and spending your money.

When your attorneys can act for you

Your attorneys can use this lasting power of attorney only after it has been registered and stamped on every page by the Ofice of

the Public Guardian. Your attorneys can make decisions for you as soon as this lasting power of attorney is registered – both when you have mental capacity and when you lack mental capacity, unless you put a restriction in this lasting power of attorney.

The Mental Capacity Act

Your attorneys cannot do whatever they like. They must follow the principles of the Mental Capacity Act 2005.

Guidance about these principles is in the Mental Capacity Act Code of Practice. Your attorneys must have regard to the Code of

Practice. They can get a copy from The Stationery Ofice at

tso.co.uk or read it online at gov.uk/power-of-attorney

Principles of the Act that your attorneys must follow

1Your attorneys must assume that you can make your own decisions unless they establish that you cannot do so.

2Your attorneys must help you to make as many of your own decisions as you can. They cannot treat you as unable to make the decision in question unless all practicable steps to help you to do so have been made without success.

3Your attorneys must not treat you as unable to make the decision in question simply because you make an unwise decision.

4Your attorneys must make decisions and act in your best interests when you are unable to make the decision in question.

5Before your attorneys make the decision in question or act for you, they must consider whether they can make the decision or act in a way that is less restrictive of your rights and freedom but still achieves the purpose.

Your best interests

Your attorneys must act in your best interests in making decisions for you when you are unable to make the decision yourself. They must take into account all the relevant circumstances.

This includes, if appropriate, consulting you and others who are interested in your welfare. Any guidance you add may assist your attorneys in identifying your views.

Cancelling this lasting power of attorney

You can cancel this lasting power of attorney at any time before or after it is registered as long as you have mental capacity to cancel it. Please read the guidance available at

gov.uk/power-of-attorney

How to ill in this form

• Tick the boxes that apply like this 

•Use black or blue ink and write clearly

•Cross through any boxes or sections that don’t apply to you, like this:

Any other names you are known by in inancial

documents or accounts

•Don’t use correction luid – please cross out any mistakes and rewrite nearby. All corrections must be initialled by the person completing that section of the form (and their witness) like this:

Any other names you are known by in inancial

documents or accounts
AWILLIAM EDWARD SMITH
A.S.B / W.E.S.	SMYTH

•Your application could be rejected if your intentions are not clear and explicit. If you are in any doubt, please start again on a new copy of the form.

What happens after you’ve illed it in?

The next step is to register it. You or your

attorneys can do this at any time. The person applying will need to ill in a registration form

and may need to pay a fee at that time. They will also need to send notices to the ‘people to be told’ named at part A when the application

to register this lasting power of attorney is made. You can ind out more and download

the registration form at direct.gov.uk/

lparegistration

The ‘people to be told’ are given time to raise any concerns or objections. This means the earliest the Ofice of Public Guardian can

register this lasting power of attorney is 4 weeks after they notify the donor or attorneys that an application to register has been received.

Your lasting power of attorney will end if it can no longer be used. For example, if a sole attorney dies or can no longer act for you and no replacement attorney has been named in this lasting power of attorney. Please read the guidance available at

gov.uk/power-of-attorney

Helpline

0300 456 0300

8gov.uk/power-of-attorney

Valid only with Ofice of the Public Guardian stamp

First names

Last name

Date of birth

D D M M Y Y Y Y

2About the attorneys you are appointing

Postcode

Any other names you are known by in inancial

documents or accounts

Your irst or only attorney

Mr Mrs Ms Miss Other title

First names of your irst or only attorney

Last name of your irst or only attorney

Date of birth of your irst or only attorney

D D M M Y Y Y Y

Address and postcode of your irst or only attorney

Postcode

Your second attorney

Please cross through this section if it does not apply.

Mr Mrs Ms Miss Other title

First names of your second attorney

Last name of your second attorney

Date of birth of your second attorney

D D M M Y Y Y Y

Address and postcode of your second attorney

Postcode

If you are appointing more than two attorneys, use continuation sheet A1 to tell us about your other attorneys.

Other attorneys you are appointing

Number of attorneys named in continuation sheet A1 attached to this lasting power of attorney

Cross through this box if this does not apply

Helpline

0300 456 0300

8gov.uk/power-of-attorney

Valid only with Ofice of the Public Guardian stamp

Company name

Are you appointing this trust corporation to act as an

attorney, or replacement attorney?

Address

Postcode

If you are appointing more than one replacement, use continuation sheet A1 to tell us about your other replacement attorneys.

Other replacement attorneys you are appointing

Number of replacement attorneys named in continuation sheet A1 attached to this lasting power of attorney

Cross through this box if this does not apply

Helpline

0300 456 0300

8gov.uk/power-of-attorney

Valid only with Ofice of the Public Guardian stamp

4How you want your attorneys to make decisions

Thinking about how you want your attorneys to make decisions

!will be appointed to make all decisions jointly.

•Jointly: this means that the attorneys must make all decisions together.  For further information on appointing your attorneys jointly, see the separate guidance.

•Jointly and severally: this means that attorneys can make decisions together and separately. This might be useful, for example, if one attorney is not available to make a decision at a certain time. If one attorney cannot act the remaining attorney is able to continue to make decisions.

•Jointly for some decisions, and jointly and severally for other decisions: this means that your attorneys must make certain decisions together and may make certain decisions separately. You

will need to set out below how you want this to work in practice.If you leave this section blank, your attorneys

Choosing which decisions must be made together and which decisions may be made separately – how this will work in practice

•Please make your intentions clear about how your attorneys are to make decisions about running bank accounts and savings accounts, making or selling investments and selling property, and spending your money.

•Please check that your intentions will work in practice – it may not be possible to register or use this lasting power of attorney if, for example, a bank or building society account cannot be operated as you wish.

Jointly

Jointly and severally

Go to section 5 and cross through the box below

Go to section 5 and cross through the box below

5About restrictions and conditions

Putting restrictions and conditions into words

•You should read the separate guidance for examples of conditions and restrictions that will not work in practice.

•Your attorneys must follow any restrictions or conditions you put in place. But it may not be possible to register or use this lasting power of attorney if a condition is not workable.

•Either: give any restrictions and conditions about property and inancial affairs here

•Or: if you would like your attorneys to make decisions with no restrictions or conditions, you should cross through this box.

6About guidance to your attorneys

Putting guidance into words

•Any guidance you add may help your attorneys to identify your views. You do not have to add any.

•Your attorneys do not have to follow your guidance but it will help them to understand your wishes when they make decisions for you.

•Either: Give any guidance about property and inancial affairs here

•Or: if you have no guidance to add, please cross through this box.

Restrictions and conditions about property and inancial affairs

If you need more space, use continuation sheet A2

Guidance to your attorneys about property and inancial affairs

If you need more space, use continuation sheet A2

7About paying your attorneys

Professional charges

•Professional attorneys, such as solicitors and accountants, charge for their services. You can also choose to pay a non-professional person for their services. You should discuss payment with your attorneys and record any agreement made here to avoid any confusion later.

•You can choose to pay non- professional attorneys for their services, but if you do not record any agreement here they will only be able to recover reasonable out-of-pocket expenses

Charges for services

If you need more space, use continuation sheet A2

For further information on paying attorneys, please see the separate guidance.

Helpline

0300 456 0300

8gov.uk/power-of-attorney

Valid only with Ofice of the Public Guardian stamp

The irst or only person to be told

Please cross through this section if it does not apply.

Mr Mrs Ms Miss Other title

First names of irst or only person to be told

Last name of irst or only person to be told

Address and postcode of irst or only person to be told

Postcode

The second person to be told

Please cross through this section if it does not apply.

Mr Mrs Ms Miss Other title

First names of second person to be told

Last name of second person to be told

Address and postcode of second person to be told

Postcode

Helpline

0300 456 0300

8gov.uk/power-of-attorney

Valid only with Ofice of the Public Guardian stamp

Before signing please check that you have:

•illed in every answer that applies to you

•crossed through blank boxes that do not apply to you

•illed in any continuation sheets

•crossed through any mistakes you have made

•initialled any changes you have made.

People to be told when the application to register this lasting power of attorney is made

I have chosen the people to be told, and have chosen one person to sign the certiicate of understanding at

part B.

No changes may be made to this lasting power of

attorney and no continuation sheets may be added after part A has been illed in and signed. If any change

appears to have been made, this lasting power of attorney

will not be valid and will be rejected when an application is

made to register it.

By signing (or marking) on this page, or by

directing someone to sign continuation sheet A3:PFA, I conirm all of the following:

Statement of understanding

I have read or had read to me:

•the section called ‘Information you must read’ on page 2

•all information contained in part A and any continuation sheets to part A of this lasting power of attorney.

I appoint and give my attorneys authority to make decisions about my property and inancial affairs,

including when I cannot act for myself because I lack mental capacity, subject to the terms of this lasting power of attorney and to the provisions of the Mental Capacity Act 2005.

OR

I do not want anyone to be told, and have chosen two people to sign certiicates of understanding at part B.

If you cannot sign this lasting power of attorney you can make a mark instead.

If you cannot sign or make a mark use continuation sheet A3:PFA 

Signed (or marked) by the person giving this lasting power of attorney and delivered as a deed

Sign with usual signature

Date signed or marked

D D M M Y Y Y Y

!at the same time as you sign (or mark) part A.

You must sign (or mark) and date part A here before parts B and C are signed and dated.Sign (or mark) and date each continuation sheet

The witness should be independent of you and:

•Must be 18 or over.

•Cannot be an attorney or replacement attorney named at part A or any continuation sheets to this lasting power of attorney or the employee of any trust corporation named as an attorney or replacement attorney.

•Can be a certiicate provider at part B.

•Can be a person to be told when the application to register this lasting power of attorney is made.

•Must initial any changes made in Part A.

Witnessed by

Signature of witness

Full names of witness

Address and postcode of witness

Helpline

0300 456 0300

8gov.uk/power-of-attorney

Valid only with Ofice of the Public Guardian stamp

Please refer to separate guidance for certiicate providers.

If the guidance is not followed, this lasting power of

attorney may not be valid and could be rejected

when an application is made to register it.

In part A (section 8) has the person giving this lasting power of attorney chosen at least one person to be told when the application to register this lasting power of attorney is made?

If yes = one certiicate provider ills in this part

If no = the irst certiicate provider ills in this part and the second certiicate provider must ill

in continuation sheet B .

The donor is the person who is giving this lasting power of attorney.

By signing below, I conirm:

My understanding of the role and responsibilities

I have read part A of this lasting power of attorney, including any continuation sheets.

I have read the section called ‘Information you must read’ on page 2 of this lasting power of attorney.

I understand my role and responsibilities as a certiicate

provider.

Statement of acting independently

I conirm that I act independently of the attorneys and of

the donor and I am aged 18 or over.

I am not:

•an attorney or replacement attorney named in this lasting power of attorney or any other lasting power of attorney or enduring power of attorney for the donor

•a family member related to the donor or any of their attorneys or replacements

•a business partner or paid employee of the donor or any of their attorneys or replacements

•the owner, director, manager or employee of a care home that the donor lives in, or a member of their family

•a director or employee of a trust corporation appointed as an attorney or replacement attorney in this lasting power of attorney.

How you formed your opinion

Before signing this certiicate you must establish that

the donor understands what it is, the authority they are giving their attorneys, and is not being pressurised into making it.

If someone challenges this lasting power of attorney, you may need to explain how you formed your opinion.

Statement of personal knowledge or relevant professional skills

Please cross through the box that does not apply.

EITHER

I have known the donor for at least two years and as more than an acquaintance. My personal knowledge of the donor is:

OR

I have relevant professional skills. (Please state your profession – for example, a GP or solicitor – and then the particular skills that are relevant to you forming your opinion – for example, a consultant specialising in geriatric care.)

My profession and particular skills are:

Helpline

0300 456 0300

8gov.uk/power-of-attorney

Valid only with Ofice of the Public Guardian stamp

Things you certify

I certify that, in my opinion, at the time of signing part A:

•the donor understands the purpose of this lasting power of attorney and the scope of the authority conferred under it

•no fraud or undue pressure is being used to induce the donor to create this lasting power of attorney

•there is nothing else which would prevent this lasting power of attorney from being created by the completion of this form.

Your signature

!Do not sign until part A of this lasting power of attorney has been illed in and signed.

Sign as soon as possible after part A is signed. If this

part is signed before part A is signed, this lasting power of attorney will not be valid and will be rejected when an

application is made to register it.

Signature of certiicate provider

Date signed

D D M M Y Y Y Y

Name and address of the person who is signing this certiicate

Mr Mrs Ms Miss Other title

First names of certiicate provider

Last name of certiicate provider

Address and postcode of certiicate provider

Postcode

Helpline

0300 456 0300

8gov.uk/power-of-attorney

Valid only with Ofice of the Public Guardian stamp

By signing below, I conirm all of the following:

Understanding of role and responsibilities

I have read the section called ‘Information you must read’ on page 2 of this lasting power of attorney.

I understand my role and responsibilities under this lasting power of attorney, in particular:

•I have a duty to act based on the principles of the Mental Capacity Act 2005 and have regard to the Mental Capacity Act Code of Practice

•I can make decisions and act only when this lasting power of attorney has been registered

•I must make decisions and act in the best interests of the person who is giving this lasting power of attorney

•I can spend money to make gifts but only to charities or on customary occasions and for reasonable amounts

•I have a duty to keep accounts and inancial records and produce them to the Ofice of the Public Guardian and/or to the Court of Protection on request.

Further statement of replacement attorney

If an original attorney’s appointment is terminated, I will replace the original attorney if I am still eligible to act as an attorney.

I have the authority to act under this lasting power of

attorney only after an original attorney’s appointment is terminated and I have notiied the Public Guardian of

the event.

!For this lasting power of attorney to be valid and registered this part should not be signed before Part A or part B have been completed, signed and dated. Sign part C as soon as possible after part B is signed.

Signed or marked by the attorney or replacement attorney as a deed and delivered (or if to be signed at their direction refer to separate guidance)

Full name of [attorney] or [replacement attorney] delete as appropriate

Date signed or marked

D D M M Y Y Y Y

•a person to be told when the application to register this lasting power of attorney is made.

The donor cannot be a witness.

The witness must see the attorney or replacement attorney sign or make a mark.

Address and postcode of witness

Postcode

Helpline

0300 456 0300

8gov.uk/power-of-attorney

Valid only with Ofice of the Public Guardian stamp