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
Adran 1
Q1. Teitl Enw llawn
Adran 1
Q2. Cyfeiriad
Adran 1
Q3. Cod post
Adran 1
Q4. Ffôn (gan gynnwys ffonau symudol)
Adran 1
Q5. E-bost
Adran 1
Q6. Os nad chi yw’r rhoddwr, nodwch eich rôl ar yr LPA neu’r EPA neu eich perthynas â’r rhoddwr.
Adran 1
Q7. Atwrnai ar yr LPA neu’r EPA
Adran 1
Q8. Gohebydd ar yr LPA neu’r EPA
Adran 1
Q9. Arall (rhowch fanylion isod)
Adran 1
Q10. Os nad chi yw’r rhoddwr, rhowch enw a chyfeiriad y rhoddwr.
Adran 1
Q11. Teitl Enw llawn
Adran 1
Q12. Cyfeiriad
Adran 1
Q13. Cod post
Adran 2
Q14. Pa ffi ydych chi’n gwneud cais am gymorth i’w thalu?
Options: LPA ar gyfer eiddo a materion ariannol; LPA ar gyfer lles personol; EPA; Ail gais am LPA eiddo a materion ariannol; Ail gais am LPA lles personol
Guidance: Mae’r rhain i’w gweld ar y llythyrau rydyn ni wedd y hanfon atoch chi.
Adran 2
Q15. Os ydych chi’n ailgyflwyno cais, darparwch unrhyw gyfeirnodau LPA
Guidance: Mae’r rhain i’w gweld ar y llythyrau rydyn ni wedd y hanfon atoch chi.
Adran 2
Q16. Rhaid i chi gynnwys unrhyw LPAs neu EPA rydych chi am ei chofrestru gyda’r cais hwn, yn yr amlen
Adran 2
Q17. Ydw, rwyf wedi amgáu’r holl ddogfennau yr wyf am eu cofrestru
Adran 2
Q18. Os ydych chi’n gwneud cais am esemptiad (i beidio â thalu ffi), ewch i Adran 3.
Adran 2
Q19. Os ydych chi’n gwneud cais am ostyngiad (i dalu hanner ffi), ewch i Adran 4.
Adran 3
Q20. Os yw’r rhoddwr yn cael unrhyw un o’r budd-daliadau canlynol, efallai na fydd yn rhaid iddo dalu ffi am ei atwrneiaeth. Rhaid iddo ddarparu tystiolaeth i ategu hyn. Ni allwch Atebwch bob cwestiwn yn yr adran hon. i wneud cais am esemptiad yn seiliedig ar:
Adran 3
Q21. Pa rai o’r budd-daliadau hyn y mae’r rhoddwr yn eu derbyn?
Options: Lwfans Byw i’r Anabl (DLA); Lwfans Gweini Cymhorthdal incwm (AA); Pensiwn y Wladwriaeth; Lwfans Ceisio Gwaith yn seiliedig ar Incwm (JSA) (SP) neu Daliad; Lwfans Cyflogaeth a Chymorth (ESA) yn gysylltiedig ag incwm Annibyniaeth Personol (PIP); Elfen Gwarant Credyd o’r Credyd Pensiwn; Budd-dal Tai; Credyd Treth Gwaith, ond ddim ond pan fo: • Credyd Treth Plant yn cael ei dalu i’r rhoddwr, neu i gwpl sy’n cynnwys y rhoddwr a / neu • Mae premiwm anabledd neu bremiwm anabledd difrifol (neu’r ddau) yn rhan o’r Credyd Treth Plant a dderbynnir gan y rhoddwr; Cymorth gyda’r Dreth Gyngor/gostyngiad yn y Dreth Gyngor (nid yw hyn yn cynnwys disgownt oherwydd anabledd neu anfeddiannaeth nac esemptiad Dosbarth U)
Adran 3
Q22. A yw’r rhoddwr wedd iawndal anaf personol?
Adran 3
Q23. Cadarnhewch un o’r dewisiadau canlynol
Options: Ni chafodd y rhoddwr unrhyw daliadau anaf personol; Roedd y taliadau anaf personol a dderbyniodd y rhoddwr yn llai nag £16,000; Roedd y taliadau dros £16,000, ond cawsant eu hanwybyddu pan gafodd y rhoddwr ei asesu ar gyfer budd-daliadau sy’n dibynnu ar brawf modd
Adran 4
Q24. I wneud cais i dalu hanner ffi
Adran 4
Q25. Os yw cyfanswm incwm blynyddol y rhoddwr cyn treth (incwm blynyddol i ddileu ffi gros) yn llai na £12,000, efallai y bydd yn gymwys i dalu hanner ffi. Rhaid rhaid i chi iddo ddarparu tystiolaeth i ategu hyn. anfon tystiolaeth o incwm y rhoddwr cyn treth atom
Adran 4
Q26. Llenwch y tabl isod i gadarnhau incwm y rhoddwr o bob ffynhonnell.
Adran 4
Q27. Darparwr Taliad neu Fudd-dal Derbyniadau Blynyddol
Adran 4
Q28. Lwfans Gweini £
Adran 4
Q29. Lwfans Byw i’r Anabl £
Adran 4
Q30. Lwfans Annibyniaeth Bersonol (PIP) £
Adran 4
Q31. Lwfans Cyflogaeth a Chymorth yn Seiliedig ar Gyfraniadau (ESA) £
Adran 4
Q32. Credyd Cynilion Pensiwn £
Adran 4
Q33. Pensiwn Gwladol £
Adran 4
Q34. Pensiynau preifat £
Adran 4
Q35. Incwm rhent o eiddo £
Adran 4
Q36. lncwm o gyflogaeth £
Adran 4
Q37. Llog o fuddsoddiadau cyfalaf a chynilion £
Adran 4
Q38. Credyd Cynhwysol £
Adran 4
Q39. Math arall o incwm £
Adran 4
Q40. Cyfanswm £
Adran 4
Q41. Os oes gennych unrhyw fath arall o incwm, cadarnhewch ei ffynhonnell
Adran 5
Q42. Rwy’n datgan bod yr wybodaeth yr wyf wedi’i rhoi yn gywir, hyd eithaf fy ngwybodaeth
Adran 5
Q43. Amgaeaf dystiolaeth i ategu’r cais hwn am leihau ffioedd atwrneiaeth arhosol
Adran 5
Q44. Ni ellir i derbyn Llofnod cyfriflenni banc fel tystiolaeth heb ddogfennau ategol gan ddarparwr y budd-dal neu’r taliad
Adran 5
Q45. Enw
Adran 5
Q46. Dyddiad llofnodi
Adran 5
Q47. Diwrnod Mis Blwyddyn