Fill - Free fillable ATF 4 - Reserve Withdrawer (Office of the Public Guardian) PDF form

ADULTS WITH INCAPACITY

(SCOTLAND) ACT 2000

Reserve Withdrawer

ATF(4)

Notes to complete

Application Form

OFFICE OF THE PUBLIC GUARDIAN (SCOTLAND)

Notes to complete

this Form

This form should only be used where an access to funds is already in place and

a reserve withdrawer requires to be appointed. Only one reserve may

be appointed. A reserve withdrawer cannot be appointed where

joint withdrawers exist. However, where joint withdrawers exist,

should circumstances change resulting in only one having

authority to act, that withdrawer may apply to appoint a

reserve.

If you require assistance to complete this form please

contact the Office of the Public Guardian (OPG) where staff

will be happy to help. Applicants should refer to the code of

practice for access to funds when considering making use of

this scheme.

Section 1 requests details of the existing authority, personal

details of the proposed reserve withdrawer, reason for appointment

and period of appointment where appropriate. Since an application relating

to the same adult has previously been authorised there is no requirement to

duplicate details of the other interested parties, for example, nearest relative,

primary carer etc. However, where personal details of such interested parties

have changed this should be shown in section 1.5.

Section 2 contains an undertaking and declaration which must be read

carefully by the applicant and the proposed reserve withdrawer, who should

both sign and date the application form.

Section 3 requires to be completed by a countersignatory who must meet the

criteria as set out in the application form. This section does not apply where

the application is made by an organisation.

Only one reserve

wthdrawer may be

identied and appointed

at a time. A reserve

withdrawer cannot be

appointed where joint

withdrawers exist.

Remember the time

restriction for lodging

your application. It is

shown opposite.

The application form must be lodged with the Public

Guardian within 14 days of the date of the countersignatory

signing the application form where required, or within 14

days of the applicant signing the form.

Use the checklist located at the end of the application form to ensure you

have completed all the information requested and then send your application

to the Public Guardian.

A fee is payable for this application and cheques should be made payable to

the “Scottish Court Service”. Details of current fees can be obtained form the

OPG or from our website.

Office of the Public Guardian (Scotland)

Hadrian House

Callendar Business Park

Callendar Road

FALKIRK, FK1 1XR

DX: 550360 Falkirk 3

LP: LP-17 Falkirk

Telephone: 01324 678300

Fax: 01324 678301

Email: opg@scotcourts.gov.uk

Website: www.publicguardian-scotland.gov.uk

The office of the Public Guardian (OPG) is open to the public from

9am to 5pm, Monday to Friday.

This leaflet is available free of charge in Braille, audiotape

large print format, and various non-English languages by phoning

the above telephone number. The OPG subscribes to Language Line

and the RNID Typetalk service.

ATF (4) 1 /7

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The information required below can be obtained from your certificate of authority.



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Title:

Surname:

Forename:

Middle Name:

House Name:

House Number:

Street:

Locality:

City:

County:

Country:

Post Code:

Tel No:

E-Mail Address:

Please identify relationship to the adult: (If family member please state exact relationship)



Please provide the reason for appointing a reserve withdrawer.

ADULTS WITH INCAPACITY

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

ATF (4) 2 /7



A reserve withdrawer may only operate within the period of time specified by the main withdrawer or for

such period as approved by the Public Guardian. You may specify a period now by completing details

below, otherwise advise this office in writing when appropriate.

Date appointment to commence Date appointment to cease



In the original application the identity of the adult’s:

• Nearest relative;

• Primary carer;

• Named person;

• Attorney/guardian; and

• Any other interested party

were provided.

There is no requirement to provide this information again, however, if for any reason their details have

changed and you have not already notified the Public Guardian, you should do so below:

You should note that a copy of this application form will be sent to the individuals you

identified in your original application, unless notified otherwise. This is to allow them the

opportunity to make comment, or indeed object, if they wish, to your proposals. This is a

requirement of the legislation.

ATF (4) 3 /7

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I understand that it is my responsibility to keep records of the exercise of my powers as withdrawer and

notify the Office of the Public Guardian directly and immediately of any change of circumstances involving

any party identified in this application for example, change of address or death of the adult etc.

I undertake to:

a) operate the designated account solely for the purpose of receiving funds transferred under the

authority of any certificate granted to me and intromitting with those funds; and

b) operate any accounts in the sole name of the adult as directed by my certificate of authority.



I declare that all information contained in this application is true and correct to the best of my knowledge

and I understand that false or misleading information may lead to the rejection of this application or the

termination of any authority already granted.

I confirm that the Office of the Public Guardian is authorised to contact appropriate bodies as it sees fit in

order to seek such information as they consider reasonable in pursuance of this application.



The Office of the Public Guardian will retain and process the information provided herein on computer. This

processing is necessary for the exercise of the statutory functions conferred on the Public Guardian by the

Adults with Incapacity (Scotland) Act 2000. By signing below I understand that I consent to this information

being processed, stored and used by the Office of the Public Guardian in the discharge of its function.

SIGNATURE OF EXISTING

WITHDRAWER:

PRINT NAME:

DATE:

SIGNATURE OF PROPOSED

RESERVE WITHDRAWER:

PRINT NAME:

DATE:

Once completed you should arrange for the countersigning officer to read the document

and complete section 3.

ATF (4) 4 /7



The countersignatory must read this application form and agree to its content and be satisfied that it is

necessary before completing and signing the declaration.

The countersignatory must read the declaration thoroughly and ensure that he/she meets the criteria as

set. If not, that person cannot act as countersignatory in this application.

The countersignatory must declare if he or she is liable to gain financially from involvement in this

application and if so the countersignatory must identify the nature and extent in the box provided. A

monetary or financial interest is known as “pecuniary interest”.



Title:

Surname:

Forename:

Middle Name:

House Name:

House Number:

Street:

Locality:

City:

County:

Country:

Post Code:

Tel No:

E-Mail Address:

Please note that the Public Guardian may at some time during this process contact the

countersignatory in relation to the application.

ATF (4) 5 /7



I declare that:

• I have known the proposed reserve withdrawer for at least one year prior to the signing of the foregoing

application and I believe the proposed reserve withdrawer to be a fit and proper person to intromit with

the adult’s funds. I believe that the information contained in this application to be true.

• I am not:

(a) a relative or person residing with the proposed reserve withdrawer or the adult; or

(b) a director or employee of the fundholder; or

any matter under this Act; or

(d) the medical practitioner who has issued the medical certificate in connection with the original

application; or

(e) a guardian of the adult or a welfare or continuing attorney of the adult; or

(f) a person who is authorised under an intervention order in relation to the adult.

Select (a) or (b) below

The nature and extent of that interest is:

(a) I have no pecuniary interest in this application.

(b) I have a pecuniary interest in this application.

ATF (4) 6 /7

The countersignatory must now complete this question providing as much relevant information as

possible.

Please comment below on how you feel that the proposed reserve withdrawer is a fit and proper person

and has the ability to carry out the functions of withdrawer:

SIGNATURE OF COUNTERSIGNATORY:

PRINT NAME:

DATE:

This application form must be lodged with the Office of the Public Guardian no later than

14 days after the date the form is countersigned.

ATF (4) 7 /7

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

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ATF 4 - Reserve Withdrawer (Office of the Public Guardian)

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