Health and Welfare Power of Attorney

Section 1 : Who is the donor for this LPA?

The 'donor' is the person appointing other people to make decisions on their behalf. The donor must be 18 or over and must be able to make their own decisions at the time their LPA is made - this is know as having mental capacity.

Title *

First name(s) *

Last name *

Date of birth (dd/mm/yyyy) *

Email address

Address line 1 *

City *

Postcode *

Section 2 : Who does the donor want to make decisions about life-sustaining treatment?

This is a very important decision. Life-sustaining treatment is care, surgery, medicine or other help from doctors that's needed to keep someone alive. The donor must choose who they want to make decisions about life-sustaining treatment if they do not have the mental capacity to decide for themselves.

Option A - The donor can add preferences and instructions later in the LPA to explain what they would like their attorneys to consider if they have to make decisions about life-sustaining treatment.

Option B - Doctors will make any decisions about life-sustaining treatment, taking into account the donor's best interest and, where possible, the views of others involved in the donor's welfare such as their attorneys and family members.

The donor:

gives their attorneys authority (option A)DOES NOT give their attorneys authority (option B)

Section 3 : Who are the attorneys? (a donor can have 1 or more attorneys)

Attorneys are people the donor appoints to make decisions on their behalf. A donor can have 1 or more attorneys; they must be 18 or over and have mental capacity to make decisions.

The most important thing is that the attorneys are people the donor can trust to respect their wishes and act in their best interests.

Note: If you require more than 3 attorneys please get in touch with us.

ATTORNEY 1

Title *

First name(s) *

Last name *

Date of birth (dd/mm/yyyy) *

Email address

Address line 1 *

City *

Postcode *

ATTORNEY 2

Title

First name(s)

Last name

Date of birth (dd/mm/yyyy)

Email address

Address line 1

City

Postcode

ATTORNEY 3

Title

First name(s)

Last name

Date of birth (dd/mm/yyyy)

Email address

Address line 1

City

Postcode

Section 4 : If there is more than one attorney, how should the attorneys make decisions?

The donor's choice here is very important as it affects how their LPA can be used. Whichever option the donor chooses, the attorneys must always act in the donor's best interest.

Jointly and severally - Attorneys can make decisions on their own or together. Most people choose this option because it's the most practical.

Jointly - Attorneys must agree unanimously on every decision, however big or small. Be careful - if one of the attorneys can no longer act, none of the other attorneys will be able to act either, unless the donor states otherwise in their instructions.

Jointly for some decisions, and jointly and severally for other decisions - Attorneys must agree unanimously on some decisions, but can make others on their own. the donor must state which decisions need to be agreed unanimously.

How should the attorneys make decisions:

Jointly and severallyJointlyJointly for some decisions, and jointly and severally for other decisions

Section 5 (optional) : Does the donor want any replacement attorneys?

Replacement attorneys step in if an original attorney can no longer act. A replacement attorney must meet the same requirements as an original attorney. This includes being 18 or over.

Title

First name(s)

Last name

Date of birth (dd/mm/yyyy)

Address line 1

City

Postcode

Section 6 : Who is the certificate provider?

Every LPA must have a certificate provider. The certificate provider is an impartial person who helps to protect the donor's interests. The certificate provider should discuss the LPA with the donor to make sure the donor understands their LPA and that no one is putting the donor under pressure to make the LPA. The certificate provider must also be 18 or over, have mental capacity and have known the donor personally for at least 2 years, or have relevant professional skills and expertise (for example, the donor's GP or solicitor). The certificate provider should be impartial and be the kind of person who speaks out if anything is wrong.

The certificate provider cannot be:

• an attorney or replacement attorney for this or any other LPA or enduring power of attorney that the donor has made
• a member of the donor's family or of an attorney's or replacement attorney's family - including husbands, wives, civil partners, in-laws and step-relations

• the boyfriend or girlfriend of the donor, an attorney or replacement attorney

• the business partner of the donor, an attorney or replacement attorney

• an employee of the donor, an attorney or replacement attorney

• anyone who runs or works for the care home where the donor lives

• anyone who has a family member that runs or works for the care home where the donor lives

• anyone who runs or works for a trust corporation appointed as an attorney in this LPA

• the donor

Title *

First name(s) *

Last name *

Address line 1 *

City *

Postcode *

Section 7 (optional) : Who should be notified about the LPA?

The donor can choose up to 3 people to be notified about the LPA application. These people have a chance to raise any concerns before the LPA is registered. Having 'people to notify' is optional, though many donors choose family members or close friends.

Note: If you require more than 3 people to notify please get in touch with us.

PERSON 1

Title

First name(s)

Last name

Address line 1

City

Postcode

PERSON 2

Title

First name(s)

Last name

Address line 1

City

Postcode

PERSON 3

Title

First name(s)

Last name

Address line 1

City

Postcode

Section 8 : Preferences and instructions

You've entered all the essential information needed for the LPA. The optional section below lets you add the donor's preferences and instructions for their attorneys. The donor can state things that the attorneys must or must not do, or give guidance that they'd like their attorneys to follow.

For example, the donor could add preferences about where they'd like to live or taking exercise. The donor could add instructions about their diet or medical treatment that fits with their beliefs.

Section 9 : Who's applying to register the LPA?

Either the donor or one or more of the attorneys can apply to register the LPA.

This LPA is being registered by:

the donorthe attorney

Section 10 : Do you have a discount code?

If you have a discount code please enter it here:

0114 265 4592

Health and Welfare

Section 1 : Who is the donor for this LPA?

Section 2 : Who does the donor want to make decisions about life-sustaining treatment?

Section 3 : Who are the attorneys? (a donor can have 1 or more attorneys)

Section 4 : If there is more than one attorney, how should the attorneys make decisions?

Section 5 (optional) : Does the donor want any replacement attorneys?

Section 6 : Who is the certificate provider?

Section 7 (optional) : Who should be notified about the LPA?

Section 8 : Preferences and instructions

Section 9 : Who's applying to register the LPA?

Section 10 : Do you have a discount code?

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