Reserve Withdrawer
Notes to complete
Application Form
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
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
DX: 550360 Falkirk 3
LP: LP-17 Falkirk
Telephone: 01324 678300
Fax: 01324 678301
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
The information required below can be obtained from your certificate of authority.
Middle Name:
House Name:
House Number:
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.
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
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.
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”.
Middle Name:
House Name:
House Number:
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
(c) a solicitor acting on behalf of the adult or any other person mentioned in this paragraph in relation to
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
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:
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
Save Form
Print Form
Reset Form
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome