Form LP1H
Section 1
Q1. Title First names Last name
Section 1
Q2. Any other names you’re known by (optional – eg your married name)
Section 1
Q3. Date of birth
Section 1
Q4. Address
Section 1
Q5. Postcode
Section 1
Q6. Email address (optional)
Section 1
Q7. LPA registration date
Section 1
Q8. OPG reference number
Section 2
Q9. Title First names Last name
Section 2
Q10. Date of birth
Section 2
Q11. Address
Section 2
Q12. Postcode
Section 2
Q13. Email address (optional)
Section 2 - continued
Q14. Title First names Last name
Section 2 - continued
Q15. Date of birth
Section 2 - continued
Q16. Address
Section 2 - continued
Q17. Postcode
Section 2 - continued
Q18. Email address (optional)
Section 3
Q19. How do you want your attorneys to work together? (tick one only)
Options: Jointly and severally; Jointly; Jointly for some decisions, jointly and severally for other decisions
Guidance: Help? For help with this section, see the Guide, part A3.
Section 3
Q20. If you choose ‘jointly for some decisions…’, you may want to take legal advice, particularly if the examples in the Guide, part A3 don’t match your needs.
Section 4
Q21. Title First names Last name
Section 4
Q22. Date of birth
Section 4
Q23. Address
Section 4
Q24. Postcode
Section 4
Q25. Title First names Last name
Section 4
Q26. Date of birth
Section 4
Q27. Address
Section 4
Q28. Postcode
Section 5
Q29. Who do you want to make decisions about life-sustaining treatment? (sign only one option)
Options: Option A – I give my attorneys authority to give or refuse consent to life-sustaining treatment on my behalf.; Option B – I do not give my attorneys authority to give or refuse consent to life-sustaining treatment on my behalf.
Guidance: If you choose this option, your attorneys can speak to doctors on your behalf as if they were you. If you choose this option, your doctors will take into account the views of the attorneys and of people who are interested in your welfare as well as any written statement you may have made, where it is practical and appropriate.
Section 5
Q30. Signature or mark
Section 5
Q31. Date signed or marked
Section 5
Q32. Full name of witness
Guidance: The witness must not be an attorney or replacement attorney appointed under this LPA, and must be aged 18 or over.
Section 5
Q33. Signature or mark
Section 5
Q34. Address
Section 5
Q35. Postcode
Section 6
Q36. Title First names Last name
Section 6
Q37. Address
Section 6
Q38. Postcode
Section 6
Q39. Title First names Last name
Section 6
Q40. Address
Section 6
Q41. Postcode
Section 7
Q42. Preferences – use words like ‘prefer’ and ‘would like’
Guidance: Preferences – use words like ‘prefer’ and ‘would like’. I need more space – use Continuation sheet 2.
Section 7
Q43. Instructions – use words like ‘must’ and ‘have to’
Guidance: Instructions – use words like ‘must’ and ‘have to’. I need more space – use Continuation sheet 2.
Section 9
Q44. Signature: donor
Guidance: By signing on this page I confirm all of the following: • I have read this lasting power of attorney (LPA) including section 8 ‘Your legal rights and responsibilities’, or I have had it read to me • I appoint and give my attorneys authority to make decisions about my health and welfare, when I cannot act for myself because I lack mental capacity, subject to the terms of this LPA and to the provisions of the Mental Capacity Act 2005 • I confirm I have chosen either Option A or Option B about life sustaining treatment in section 5 of this LPA • I have either appointed people to notify (in section 6) or I have chosen not to notify anyone when the LPA is registered before anyone signs • I agree to the information I’ve provided being used by the Office of the Public Guardian in carrying out its duties
Section 9
Q45. Date signed or marked
Section 9
Q46. Full name of witness
Guidance: The witness must not be an attorney or replacement attorney appointed under this LPA, and must be aged 18 or over.
Section 9
Q47. Signature or mark
Section 9
Q48. Address
Section 9
Q49. Postcode
Section 10
Q50. Certificate provider’s statement
Guidance: I certify that, as far as I’m aware, at the time of signing section 9: • the donor understood the purpose of this LPA and the scope of the authority conferred under it • no fraud or undue pressure is being used to induce the donor to create this LPA • there is nothing else which would prevent this LPA from being created by the completion of this instrument
Section 10
Q51. Title First names Last name
Section 10
Q52. Address
Section 10
Q53. Postcode
Section 10
Q54. Signature or mark
Section 10
Q55. Date signed or marked
Section 11
Q56. Signature: attorney or replacement attorney
Guidance: By signing this section I understand and confirm all of the following: • I am aged 18 or over • I have read this lasting power of attorney (LPA) including section 8 ‘Your legal rights and responsibilities’, or I have had it read to me • I have a duty to act based on the principles of the Mental Capacity Act 2005 and to have regard to the Mental Capacity Act Code of Practice • I must make decisions and act in the best interests of the donor • I must take into account any instructions or preferences set out in this LPA • I can make decisions and act only when this LPA has been registered • I can make decisions and act only when the donor lacks mental capacity. Further statement by a replacement attorney: I understand that I have the authority to act under this LPA only after an original attorney’s appointment is terminated. I must notify the Public Guardian if this happens.
Section 11
Q57. Date signed or marked
Section 11
Q58. Full names of witness
Guidance: The witness must not be the donor of this LPA, and must be aged 18 or over.
Section 11
Q59. Signature or mark
Section 11
Q60. Address
Section 11
Q61. Title First names Last name
Section 11
Q62. Postcode
Section 12
Q63. Who is applying to register the LPA? (tick one only)
Options: Donor – the donor needs to sign section 15; Attorney(s) – If the attorneys were appointed jointly (in section 3) then they all need to sign in section 15. Otherwise, only one of the attorneys needs to sign
Guidance: For help with this section, see the Guide, part B2.
Section 12
Q64. Title First names Last name
Section 12
Q65. Date of birth
Section 12
Q66. Title First names Last name
Section 12
Q67. Date of birth
Section 13
Q68. Who would you like to receive the LPA and any correspondence?
Options: The donor; An attorney (write name below); Other (write name and address below)
Guidance: For help with this section, see the Guide, part B3.
Section 13
Q69. Title First names Last name
Section 13
Q70. Company (optional)
Section 13
Q71. Address
Section 13
Q72. Postcode
Section 13
Q73. How would the person above prefer to be contacted?
Options: Post; Phone; Email; Welsh (We will write to the person in Welsh)
Section 14
Q74. How would you like to pay?
Options: Card; Cheque
Guidance: For help with this section, see the Guide, part B4.
Section 14
Q75. Your phone number
Section 14
Q76. I want to apply to pay a reduced fee
Guidance: You’ll need to fill in form LPA120 and include it with your application. You’ll also need to send proof that the donor is eligible to pay a reduced fee.
Section 14
Q77. I’m making a repeat application
Guidance: If you’ve already applied to register an LPA and the Office of the Public Guardian said that it was not possible to register it, you can apply again within 3 months and pay a reduced fee.
Section 14
Q78. Case number
Section 14
Q79. Payment reference
Section 14
Q80. Payment date
Section 14
Q81. Amount
Section 15
Q82. Signature or mark
Guidance: By signing this section I confirm the following: • I apply to register the LPA that accompanies this application • I have informed ‘people to notify’ named in section 6 of the LPA (if any) of my intention to register the LPA • I certify that the information in this form is correct to the best of my knowledge and belief
Section 15
Q83. Date signed
Section 15
Q84. Signature or mark
Section 15
Q85. Date signed