Lasting Powers of Attorney Questionnaire

Services for Individuals
- Private Client Law
- Property Law
  - Residential Conveyancing
  - Property Investments
Services for Businesses
- Commercial Property
- Company/Commercial Law

About Us
Our Team
Our Fees
News
Contact
Booking Form

Services for Individuals
- Private Client Services
- Property Law
  - Residential Conveyancing
  - Property Investments
Services for Business
- Commercial Property
- Company/Commercial Law
About Us
Our Team
Our Fees
News
Contact
Booking Form

Lasting Powers of Attorney Questionnaire

Property and Financial Matters

and/or

Health and Personal Welfare Matters

Thank you for your instructions.

Please complete this questionnaire as fully as possible before you see us. We will go through it with you, discuss your wishes and then prepare your Lasting Power of Attorney. Details of your appointment if made are set out below. If it is more convenient, you can download the PDF version of this questionnaire and return it to us by email or by post to our office address below.

Click here to download the PDF, or please fill out the step by step form below.

Firm’s Representative: Amaka Jackson

Appointment Date *

Time *

Hours

Minutes

Part A - Donor

(Person making POA)

1. Your details

Title

Forename:

Surname:

Your Date of Birth

Your Address

City

County

Post Code

Telephone number

Have you been known by any other names e.g. maiden names?

Part B - Attorneys

You can appoint one attorney to conduct your affairs of as many attorneys as you require.

Attorney

Title

Forename:

Surname:

Date of Birth

Address

City

County

Post Code

Telephone number

4. How your attorney(s) should act for you.TogetherTogether and IndependentlyTogether in respect of some matters and together and independently in respect of others.

5. Do you wish to place any restrictions and/or conditions on your attorney(s)?YesNo

If yes, which restrictions would you like to place on your attorneys?

6. Would you like your attorney(s) to Consider any guidance when acting on your behalf?YesNo

If yes, please summarise your guidance below:

7. Would you like to pay your attorney(s) a fee to act as your attorney(s)?YesNo

If yes, what fee would you like to pay your attorney(s)?

Part C - Life Sustaining Treatments (Health and Personal Welfare only)

8. Please choose one of the following:I want to give my attorney(s) authority to give or refuse consent to life-sustaining treatment on my behalf.I do not want to give my attorney(s) authority to give or refuse consent to life-sustaining treatment on my behalf.

Part D - People to be notified

You need to notify at least one person when the application for registering your LPA.

9. Details

Title

Forename:

Surname:

Date of Birth

Address

City

County

Post Code

Telephone number

Part D - Certificate Provider

13. Your certificate provider needs to have be ONE of the following:A person that has known the donor personally for the last two years (can’t be a family member, attorney, owner/employee of care home, business partner)A registered healthcare professional (includes GP).A registered social workerA barrister, solicitor or advocate.An Independent Mental Capacity Advocate (IMCA)

14. Certificate Provider Details

Title

Forename:

Surname:

Date of Birth

Your Address

City

County

Post Code

Telephone number

Registration Fees

(a) Exemption

Are you in receipt of any of the following means tested benefits?YesNo

If yes, please provide details belowIncome SupportIncome based Employment & Support AllowanceIncome based Job Seeker’s AllowancePension Guarantee Credit element of State Pension CreditA combination of Working Tax Credit and either Child Tax Credit, Disability Element Working Tax Credit or Severe Disability Element (within the Working Tax Credit). This does not include Disability Living Allowance or Invalidity BenefitHousing Benefit or Council Tax Benefit (not the 25% single person reduction)

(b) Remission

Is your gross annual income below £12,000?YesNo

If yes, please provide details below

If your income is below £12,000 per annum, you will be eligible for a reduced registration fee of £55 per document.

If you are not eligible for either an exemption or remission the fee is £82.00 per document.

Confirmation of Instructions

I/We confirm that the instructions I/We have given represent our intentions in relation to my/our Lasting Power of Attorney for Property and Affairs.

TitleMrMrsMissOther

Full Name

Signature

Start signing your signature here

Date

Book your consultation

Name *

Email Address *

Phone Number *

Area of Law *

Case Description *

Latest Insights

Answering Frequently Asked Questions About Probate

Dec 21, 2023 | Probate

Administering the estate of someone who has passed away is known as probate.Detailed paperwork, extensive...

Get in touch



Parkshot House
5 Kew Road Richmond
TW9 2PR



020 8332 2069



info@jacksonlonge.com

Quick Links

Booking Form
Get a Conveyancing Quote
Our Fees
Cookie Policy
Privacy Policy
Complaint Procedure

Authorised and Regulated by the Solicitors Regulation Authority (SRA)
SRA Number: 614838
VAT Number: 263 4840 96
Company Registration Number: 07670507

Jackson Longe Limited is a private company, limited by shares, incorporated in England and Wales.