Form LPA120
Section 1
Section 1. Your details
Section 1
Q1. Title
Section 1
Q2. Full name
Section 1
Q3. Address
Section 1
Q4. Postcode
Section 1
Q5. Phone (to include mobiles)
Section 1
Q6. Email
Section 1
Q7. If you are not the donor, please state your role on the LPA or EPA or your relationship to the donor
Section 1
Q8. Attorney on the LPA or EPA
Section 1
Q9. Correspondent on the LPA or EPA
Section 1
Q10. Other (please specify below)
Section 2
Section 2. The application
Section 2
Q11. Which fee are you applying for help to pay?
Options: LPA for property and financial affairs; LPA for health and welfare; EPA; Repeat application for an LPA for property and financial affairs; Repeat application for an LPA for health and welfare
Guidance: You can find these on the letters we have sent you
Section 2
Q12. If you are making a repeat application, please provide any LPA reference numbers
Guidance: You can find these on the letters we have sent you
Section 2
Q13. You must include any LPAs or EPA you want to register along with this application in the envelope
Section 2
Q14. Yes, I have enclosed all the documents I wish to register
Section 2
Q15. If you are applying for an exemption (to pay no fee), go to Section 3.
Section 2
Q16. If you are applying for a remission (to pay half a fee), go to Section 4.
Section 3
Section 3. Apply for a fee exemption
Guidance: If the donor receives any of the following benefits they may not have to pay a fee for their power of attorney. They must provide evidence to support this. You cannot apply for an exemption based on:
Section 3
Q17. Which of these benefits does the donor receive?
Options: Disability Living Allowance (DLA); Income support; Attendance Allowance (AA); Income-based Jobseeker’s Allowance (JSA); State Pension (SP); Personal Independence Payment (PIP); Guarantee Credit element of State Pension Credit; Housing Benefit; Working Tax Credit, but only when: • Child Tax Credit is being paid to the donor, or to a couple which includes the donor and / or • There is a disability premium or severe disability premium (or both) to the Child Tax Credit received by the donor; Council Tax Support / Council Tax reduction (this does not include disability or inoccupancy discount or Class U exemption)
Section 3
Q18. Has the donor received personal injury damages?
Options: The donor did not receive any personal injury payments; The donor did receive personal injury payments, but they were less than £16,000; The payments were more than £16,000, but were ignored when the donor was assessed for one of the benefits listed above
Guidance: If the donor has been awarded personal injury damages of more than £16,000 which were ignored when they were assessed for one of the benefits above, they won’t qualify for an exemption.
Section 4
Section 4. Apply for a fee remission
Guidance: To apply for a fee remission, if the donor’s total annual income before tax (gross annual income) is less than £12,000, they may be eligible to pay half a fee. They must provide evidence to support this. You must send us evidence of the donor’s income
Section 4
Q19. I confirm the donor’s income is less than £12,000 before tax
Section 4
Q20. Please complete the table below confirming the donor’s income from all sources.
Section 4
Q21. Payment or Benefit Provider
Section 4
Q22. Total Annual Receipt
Section 4
Q23. Attendance Allowance £
Section 4
Q24. Disability Living Allowance £
Section 4
Q25. Personal Independence Allowance (PIP) £
Section 4
Q26. Contribution-Based Employment Support Allowance (ESA) £
Section 4
Q27. Pension Savings Credit £
Section 4
Q28. State Pension £
Section 4
Q29. Private pensions £
Section 4
Q30. Property rental income £
Section 4
Q31. Income from employment £
Section 4
Q32. Interest from capital investments and savings £
Section 4
Q33. Universal Credit £
Section 4
Q34. Other form of income £
Section 4
Q35. Total £
Section 4
Q36. If you have any other form of income, confirm its source
Section 5
Section 5. Declaration
Guidance: I declare that the information I have given is true to the best of my knowledge. I enclose evidence to support this application for a reduction of power of attorney fees. Bank statements cannot be accepted as evidence without supporting documentation from the benefit or payment provider.
Section 5
Q37. Signature
Section 5
Q38. Name
Section 5
Q39. Date signed
Guidance: Day Month Year