A1 Continuation sheet A1 Additional people
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1 Lasting power of attorney for health & welfare A1 Continuation sheet A1 Additional people Use this continuation sheet for details of all additional attorneys, replacement attorneys, or people to be told. Make copies of this sheet before filling it in if you need more than one sheet. About the additional people For each additional person, provide the For example: following details Third attorney Whether you want them to act as an attorney, Mr John Smith, replacement attorney or person to be told 3 London Street, If you don t make your requirements for each Posttown, PC6 9ZZ! person clear this lasting power of attorney could 19 January 1960 be rejected at registration Their title, full name, address including postcode) Their date of birth or: Second replacement attorney Mrs Susan Jones 27 Lincoln Road, Posttown, PC7 9XX 12 December 1962 About you Name of person who is giving this lasting power of attorney Signed or marked by or signed by the direction of) the person giving this lasting power of attorney or marked Signature or mark) of the person who is giving this lasting power of attorney Please attach this sheet to the back of your lasting power of attorney before you sign and date the And number your continuation sheets consecutively. LPA ) Crown Copyright 2011 opg_hw_cont-sheets
2 Lasting power of attorney for health & welfare Continuation sheet A2 how your attorneys make decisions jointly and A2 severally, restrictions & conditions, guidance, payment Only use this continuation sheet to provide further additional information about how you want your attorneys to act. Make copies of this sheet before filling it in if you need more than one sheet. About the additional information For each additional piece of information you are providing, state whether it relates to: Which decisions your attorneys should make jointly and which decisions they should make jointly and severally only if this applies) Restrictions and conditions Guidance to your attorneys Paying your attorneys About you Name of person who is giving this lasting power of attorney Signed or marked by or signed by the direction of) the person giving this lasting power of attorney or marked Signature or mark) of the person who is giving this lasting power of attorney Please attach this sheet to the back of your lasting power of attorney before you sign and date the And number your continuation sheets consecutively. opg_hw_cont-sheets
3 Page 1 of 2 A3:HW Continuation sheet A3 health and welfare) if you cannot sign or make a mark Lasting power of attorney for health and welfare Use this continuation sheet if you cannot sign or make a mark at part A of your lasting power of attorney. The person signing on behalf of the person giving this lasting power of attorney must sign in the person s presence and in the presence of two witnesses. sign in their own name not also be a witness. Full name of the person signing Do not sign Do not sign Option A! Option B both boxes! both boxes I want to give my attorneys authority to give or refuse consent to life-sustaining treatment on my behalf. Signature of someone signing for the person who is giving this lasting power of attorney I do not want to give my attorneys authority to give or refuse consent to life-sustaining treatment on my behalf. Signature of someone signing for the person who is giving this lasting power of attorney The date you sign! here must be the same as the date you sign below. The date you sign! here must be the same as the date you sign below. Signature of someone signing on behalf of the person giving this lasting power of attorney I confirm that I have signed at Option A or Option B in the presence of and directed by the person giving this lasting power of attorney and in the presence of two witnesses! Sign and date Option A or Option B above, and each continuation sheet, at the same time as you sign part A here. You must sign and date part A here before parts B and C are signed and dated. Signed as a deed and delivered in the presence of and directed by the person giving this lasting power of attorney and in the presence of two witnesses This continuation sheet has two pages. Two witnesses must sign on the next page pages of continuation sheet A3:HW to the back of your lasting power of attorney after they have been signed and dated. Continues over opg_hw_cont-sheets-v9.indd 1
4 Page 2 of 2 A3:HW Continuation sheet A3 health and welfare) if you cannot sign or make a mark continued) Lasting power of attorney for health and welfare Each witness Must be 1 or over. Cannot be an attorney or replacement attorney named at part A or any continuation sheets A to this lasting power of attorney. Witnessed by Signature of first witness Can be a certificate 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. Also witnessed by Signature of second witness Full names of first witness Full names of second witness Address and postcode of first witness Address and postcode of second witness Postcode Postcode About you Name of person who is giving this lasting power of attorney This continuation sheet has two pages. pages of continuation sheet A3:HW to the back of your lasting power of attorney after they have been signed and dated. opg_hw_cont-sheets-v9.indd 2 2/7/09 09:56:57
5 Page 1 of 2 B Continuation sheet B declaration by your second certificate provider: certificate to confirm understanding Your second certificate provider signs and dates this continuation sheet Declaration by the person who is signing this certificate Please refer to separate guidance for certificate providers. How you formed your opinion 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 property and financial affairs section, or health and welfare section 9) 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 = you only need one certificate provider so you do not need to fill in this continuation sheet If no = the second certificate provider must fill in this continuation sheet The donor is the person who is giving this lasting power of attorney. By signing below, I confirm: 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 certificate provider. Statement of acting independently Lasting power of attorney for health & welfare Before signing this certificate 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: I confirm that I act independently of the attorneys and of the donor and I am aged 1 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 for property and financial affairs only). 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: continuation sheet B pages to the back of your lasting power of attorney after you sign and date the Continues over opg_hw_cont-sheets-v9.indd 1 10/7/09 12:42:43
6 Page 2 of 2 B Declaration by the person who is signing this certificate continued) Lasting power of attorney for health & welfare Continuation sheet B continued) declaration by your second certificate provider: certificate to confirm understanding 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 filled 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 certificate provider Name and address of the person who is signing this certificate Mr Mrs Ms Miss Other title First names of certificate provider Last name of certificate provider Address and postcode of certificate provider Postcode pages of continuation sheet B to the back of your lasting power of attorney after you sign and date the opg_hw_cont-sheets-v9.indd 2 10/7/09 12:42:43
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