Download our Questionnaire here
The following information is about the person acting for the patient.
Name Required
Address Required
Date of Birth Required
Occupation Required
National Insurance number Required
Tel no (home/work/mobile) Required
Email Required
Status Required Single Married Divorced Widow Partner
To be completed by or on behalf of the donor:
Name Required, including any other names you are known by or have been known by in the past
Details of health including diagnosis and prognosis
Details of medication that may affect decision making abilityRequired
Treating doctors name, address and telephone numberRequired
Husband/wife/partner Required
ChildrenSet in order of age give their gender and date of birth
Other DependantsPlease state any other dependants
Do you have a will? If you do please provide a copy of your latest will. Who holds the original will?
Has any other application been made to the Court of Protection?If so, please provide a copy of the document.
Full address of your home? Is it freehold or leasehold?
How is your home held? Solely or jointly? If joint, is it as joint tenants or tenants in common? Where possible please provide a copy of your deeds. If not, please advise where the deeds are held.
List other assets held, their approximate value and say if held solely or jointly and if jointly held, with whom.
Bank and Building Society Accounts
Pension Funds
Life Insurance
Business
List details of state and occupational pensions, state Benefit and any other income. Please state the amount received and if weekly, monthly or annually
Give details of state benefits you receive (e.g. pension credit, council tax credits)
Please give details of all liabilities including long term secured loans
Give the name, date of birth, address, and telephone number of your attorney/s and their relationship to you
Do you want your attorneys to act together or together and Independently? Together Independently
Do you want others to act as attorney should your main attorney be unable to do so(for example, they predecease?) If so give the name, date of birth, address, occupation, and telephone number of your replacement attorney/s and their relationship to you
Do you want your replacement attorneys to act together or together and Independently? Together Independently
Give the name, date of birth, address and telephone number of those people you wish to be informed that you are making an LPA. You may chose up to 5 people but should give details of at least three.
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