01635 292356 
This form, just like the Will Instruction Form, is one you will become extremely familiar with! You will use it every time you take instructions from a client to complete their Lasting Power of Attorneys. Have a read through and ensure you feel comfortable with the information that needs gathering from your client. 
LPA QUESTIONNAIRE - Property and Financial and/or Health and Welfare 
This LPA is for Property & Finance and/or Health & Welfare (Please delete as appropriate). 
Could you let us have the following information about yourself:- 
Your full name 
Other names you are known by or have been known by in the past 
(i.e. maiden name) 
Date of birth 
Telephone number 
(landline or mobile) 
E-mail address 
Choice of Attorney (the person you wish to take control of your property and financial affairs and/or health and welfare matters) 
Consider the following when choosing your attorney: 
• They must be over 18 
• They must not be an undischarged or interim bankrupt person, if you are making a property and affairs power 
• They must be absolutely trustworthy and possess appropriate skills to make decisions on your behalf 
• They should be people with whom you have a settled and easy relationship and if more than one, who get on with each other well, or who are likely to do so 
• You can appoint one attorney, but it is advisable to appoint more than one to lessen the chance of abuse of the power and ensure continuity in case the attorney cannot act 
• They can be family members (it is common to appoint partners and children), friends or your professional adviser, such as your solicitor – if the latter is prepared to accept the role. 
• They must agree to be your attorney and should understand the role they will be fulfilling. 
• If they know the people who will be notified on registration, they should have a good relationship with them 
• They must always act according to the principles laid down in the Mental Capacity Act 2005 and in your best interests as set out in the Act and follow the guidance contained in the Code of Practice. 
• They will need to sign the Lasting Power of Attorney document accepting their role and their responsibilities 
Could you therefore let us have the following information about each of the Attorneys you wish to appoint:- 
Attorney 1 
Full name 
Date of birth 
Telephone number 
(landline or mobile) 
E-mail address 
Current/Previous Occupation 
Relationship to you 
Attorney 2 
Full name 
Date of birth 
Telephone number 
(landline or mobile) 
E-mail address 
Relationship to you 
*If there are more than two attorneys, please indicate you have more than two and add the details on a separate sheet. 
How do you want them to operate in their role as Attorney? 
• If you have more than one attorney, consider how you want them to act. Jointly, i.e. always together, or jointly and severally, i.e. together and independently so that they can sometimes sign together and sometimes separately. This works well when the attorneys do not live near to each other, or if one were to retire or die, then the other attorney could still act 
• You can direct that some tasks, e.g. selling your house, must be dealt with together and some tasks jointly and severally 
• If they are appointed together, they MUST be able to sign together which can be difficult in practice and if one dies, loses mental capacity or becomes bankrupt (if the power is a financial power) the document can no longer be used 
• If you appoint your spouse or civil partner, be aware that dissolution of the marriage or civil partnership terminates the appointment of your spouse/civil partner, unless you have indicated otherwise 
I would like my attorneys to act (tick the relevant box): 
and Severally 
My special instructions about how my Attorneys should act or who the replacement Attorney or Attorneys (see below) should replace are: 
Do you want replacement Attorneys and, if so, when? 
• It is especially useful to have a replacement attorney if your original attorneys have been appointed jointly, but is also sensible as a way of “Hoping for the best and preparing for the worst!” 
• Your choice of replacement attorney or attorneys should be considered in the same way as your original attorney, so read the section above on the choice of attorney 
• You need to decide which attorney they will be replacing (in the absence of a choice from you, a sole replacement attorney will replace the first attorney who needs replacing). 
My chosen replacement attorney is: 
Full name 
Date of birth 
Telephone number 
(landline or mobile) 
E-mail address 
Relationship to you 
*If there is more than one replacement attorney, please indicate you have more than one and add the details on a separate sheet. 
Do you wish to place any restrictions and/or conditions on the attorneys you are appointing? 
• You may wish to consider restricting the occasions when the attorneys should act for you 
• You do not have to restrict the attorneys as such restriction will be legally binding and could cause difficulties 
• If you do, you must be careful that the document can still work. 
My restrictions are : 
Do you want to give your attorneys guidance? 
• You may, for example, feel it would be helpful to give your attorneys some idea of the way in which, ideally, you would like your finances dealt with if you no longer have capacity. In relation to a Health and Welfare LPA you may want, for example to indicate where you would want to live and what treatments you may prefer not to have if you lose mental capacity 
• Please consider carefully the types of decisions you would like your attorney to make on your behalf, so we can discuss this in our meeting and draft the power to meet your wishes 
I would like the following guidance to be added to my LPA : 
Paying your attorneys 
• Generally, family and friends would not expect to be paid, although you may wish for it to be made clear that their out-of-pocket expenses should be covered 
• If you have professional attorneys, they must be paid for their work and this should be covered 
Do you want to give your Attorneys authority to access your Will? 
*Please circle your answers 
*Yes / No 
Do you want to give your Attorneys authority to access your Medical Records for financial purposes eg a claim for Continuing Healthcare? 
*Yes / No 
Notifying people of the registration of the power 
You can choose up to five people to be notified when the LPA is registered with the Office of the Public guardian. Once the power is registered, it can be used by your attorney. It is an important safeguard as they can raise concerns on your behalf. It is important that you think carefully as to the people you choose. Ideally they should be a person: 
• With whom you are likely to have contact throughout your life 
• Who is interested in your best interests and well being 
• You should tell them that you are naming them and make sure that they will take their role seriously as it is for your protection 
• You need to supply their full personal details as above 
• If you decide that no one is to be notified, you will need to have two certificate providers 
• Please share the enclosed information with those to be notified so that they can access more information 
I would like to notify the following people: 
1st person 
Full name 
Relationship to you 
2nd person 
Full name 
Relationship to you 
*If there are more than two people being notified, please indicate you have more than two and add the details on a separate sheet. 
Who will be the Certificate Provider? (A person that will confirm that you understand the LPA and that you have not been put under any pressure to make it). 
• They must be someone of your choice and are over 18 years of age 
• Someone whom you have known for at least two years, or 
• Someone who, on account of their professional skills and expertise, considers themselves competent to make the judgements necessary to give the certificate, such as a lawyer or doctor 
A Certificate Provider cannot be: 
• A member of your family 
• A family member of any of your attorneys 
• Your business partner or paid employee 
• Any attorney appointed by you under this document or another LPA or Enduring Power of Attorney 
• The owner, manager or employee of a care home in which you are living, or their family member or partner 
• A director or employee of a trust corporation appointed as your attorney 
Please note: 
If we are not appointed as attorneys, we can act as Certificate Provider but, in order to fulfil the requirements of the document itself, we will need to see you. 
If we agree to act as attorney, we cannot act in the role of Certificate Provider. 
I would like my Certificate Provider to be: 
Full name 
Telephone number 
E-mail address 
How long have you known them? 
How do you know them? 
In the case of sole property/accounts, I would like you to also prepare a General Power of Attorney for immediate use 
*Yes / No 
In the case of jointly owned property/accounts, I would like you to also prepare a Trustee Power of Attorney for immediate use 
*Yes / No 
See over for types of decisions that can be made with an unrestricted Property and Financial Power 
I confirm that the information contained in this form is correct, as far as I know and would like you to draft my Lasting Power of Attorney documents for Property and Finance and/or Health and Welfare (Delete as appropriate) 
Signature__________________________________ Date __________________ 
• Buying or selling property 
• Opening, closing or operating any bank, building society or other account 
• Giving access to the donor’s financial information claiming, receiving and using (on the donor’s behalf) all benefits, pensions, allowances and rebates 
• Receiving any income, inheritance or other entitlement on behalf of the donor 
• Dealing with the donor’s tax affairs 
• Paying the donor’s mortgage, rent and household expenses 
• Insuring, maintaining and repairing the donor’s property 
• Investing the donor’s savings 
• Making limited gifts on the donor’s behalf 
• Paying for private medical care and residential care or nursing home fees 
• Applying for any entitlement to funding for NHS care, social care or adaptations 
• Using the donor’s money to buy a vehicle or any equipment or other help they need 
• Repaying interest and capital on any loan taken out by the donor 
• Where the donor should live and who they should live with 
• The donor’s day-to-day care, including diet and dress 
• Consenting to or refusing medical examinations and treatment on the donor’s behalf 
• Arrangements needed for the donor to be given medical, dental or optical treatment 
• Assessments for and provision of community care services 
• Whether the donor should take part in social activities, leisure activities, education or training 
• The donor’s personal correspondence and papers 
• Rights of access to personal information about the donor, or 
• Complaints about the donor’s care or treatment 
Unlike the Lasting Power of Attorney for Property and Financial Affairs, the Health and Welfare Lasting Power of Attorney can only be used if and when you do not have the capacity to make a health and welfare decision for yourself. 
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