Fill - Free fillable Application Form (Office of the Public Guardian) PDF form

ADULTS WITH INCAPACITY

(SCOTLAND) ACT 2000

Renewal of Authority

ATF(6)

Notes to complete

Application Form

OFFICE OF THE PUBLIC GUARDIAN (SCOTLAND)

Organisations - Fitness to Access Funds

ATF(1) – Request Account information

ATF(2) - Access to Funds

ATF(3) - Additional Joint Withdrawers

ATF(4) - Reserve Withdrawer

ATF(5) - Variation of Transactions

ATF(7) - Transition of Authority

Other application forms

available in this series:

Notes to complete this

Form

This form relates solely to the renewal of an existing authority to access funds

and should be used when:

• the existing authority is about to expire; or

• where the withdrawer has died or is no longer able to carry out the function

and a reserve withdrawer, without undue delay, wishes to apply to become

the main withdrawer.

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 applicant, and all other existing or proposed

new joint/reserve withdrawers. 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, any change of address or change of primary carer,

for example, must be notified to the Public Guardian.

Section 2 requests financial information, the anticipated use of

funds, the period of authority requested and some information

regarding the use of the existing authority.

The applicant must identify the anticipated ongoing expenditure required to

meet the adult’s financial needs and complete the appropriate section.

This information is requested monthly to fit in with a time scale used

by most financial institutions.

Where personal

details of interested

parties have

changed this should

be shown in section

1.5 of the application

form.

When you calculate the ongoing expenditure you should remember to take

inflation into account as was done in the original application.

The examples below show how this can be done.

Example 1: If the adult pays rent, currently payable at £100 monthly and

calculated at £1,200 in year one (£100 x 12 months), you may wish to allow

£1,360 to cover potential increase in year two and possibly £1,580 for

year three. This would total £4,140 over the period of three years.

Therefore you may wish to request £115 per month (£4,140

divided by 36 months) for rent in your application form. You

should apply the same logic in terms of each heading. If you

are not sure the staff at this office will assist.

Example 2: If the adult is in a care home and costs are

currently payable at £250 weekly that would work out at

£13,000 in year one (£250 x 52 weeks). If you estimate that

costs might go up by approximately 10%, in year two you

might expect the annual cost to be £14,300 and in year three

this figure might be £15,730. So over the three year period

you may require £43,030. This could be rounded up to £43,200

to cover the full three years, which divided by 36 (months) would be

£1,200 monthly.

It is possible to apply for a lump sum and in this instance may be used where

there has been an unexpected but necessary purchase required which will be

of benefit to the adult. For example the withdrawer finds that remedial work

requires to be carried out on the roof of the adult’s home. The Public Guardian

would expect to see three written quotes providing a breakdown of the work

to be done together with the withdrawer’s preferred option and explanation

thereof before approving the lump sum in this instance.

The cost of the application and any other costs associated with the application

may be identified as part of the lump sum and can be reimbursed through the

designated account once the lump sum is paid therein.

The Public Guardian can provide you with further advice on this if required.

Remember to build

in a gure in your

calculations to cover

ination as shown in the

examples opposite.

Withdrawer must

provide a copy of the

pass book or the two

most recent monthly

statements for the

designated account

with this

application.

The period of authority is normally set at three years but may be extended or

reduced by the Public Guardian dependent on the needs of the adult and the

level of funds available. If the period is to be other than three years the reason

for such should be clearly identified in section 2.7 of the application form.

When a new certificate of authority is granted it will only provide authority

to carry out the transactions requested in this application form. If there is

any other action required which was not dealt with during the original

period of authority it requires to be highlighted in section 2.8 of the

application form.

Before considering an application for renewal of authority

the Public Guardian requires to be satisfied that the existing

process is operating effectively. The applicant must,

therefore, enclose with the renewal application a copy

of the pass book, if issued, or the last two monthly bank

or building society statements relating to the designated

account. Other documentation may be requested by

the Public Guardian. Documents will be returned to the

applicant.

Section 3 identifies that details of this application will be sent to the

adult and other persons identified in the original application and to any

other person(s) identified in this application. Where the applicant considers

that a copy of the application should not be sent to the adult as it would pose

a serious risk to the adult’s health, the applicant should tick the box. Medical

Certificate SSI No79 requires to be completed where the applicant considers

that a copy of the application should not be sent to the adult. The section

Medical Certificates in the code of practice for access to funds provides further

information.

Section 4 contains an undertaking and declaration which must be read

carefully by the applicant and, where identified, any other proposed

withdrawers, who should all sign and date the application form.

Section 5 of this form only requires to be completed by a countersignatory,

where it is proposed to appoint a new joint withdrawer or reserve withdrawer

not previously identified.

Remember the time

restriction for lodging

your application. It is

shown opposite.

In all other instances this section should not be completed. The

countersignatory must meet the criteria as set out in the application form.

This section does not apply where the application is made by an organisation.

The Public Guardian needs to confirm that the condition of the adult still

meets the criteria as set in Section 1(6) of the Act. The medical certificate

SSI No76 enclosed at the rear of this form must now be completed

by a medical practitioner and accompany your application. This

should be done before signing or having the application form

countersigned.

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 near the end of the application form to ensure

you have completed all the information requested and thereafter 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 (6) 1 /17

ADULTS WITH INCAPACITY

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

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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:

ATF (6) 2 /17

Organisation:

Department:

Number:

Street:

Locality:

City:

County:

Country:

Post Code:

Organisation List Number:

Nominated Contact for Organisation

Surname:

Forename:

Middle Name:

Contact Person’s Designation:

Tel No:

E-Mail Address:





Please provide details of all existing or proposed new joint withdrawers below.

Joint Withdrawer Joint Withdrawer

Title:

Surname:

Forename:

Middle Name:

House Name:

House Number:

Street:

Locality:

City:

County:

Country:

Post Code:

Tel No:

E-Mail Address:

Please note if a new joint withdrawer(s) is/are identified above, section 5 requires to be completed by a

countersignatory.

ATF (6) 3 /17



Is it intended that the existing reserve withdrawer continue to be available to operate along with the

applicant identified in section 1.2?

If no reserve withdrawer has been identified is it intended that one be identified now? A reserve withdrawer

can be applied for at a later time if required using form ATF(4).

If Yes, complete below If No, go to section 1.5

Title:

Surname:

Forename:

Middle Name:

House Name:

House Number:

Street:

Locality:

City:

County:

Country:

Post Code:

Tel No:

E-Mail Address:

Please note if a new reserve withdrawer is identified above, section 5 requires to be completed by a

countersignatory.

ATF (6) 4 /17

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

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 (6) 5 /17





Please provide full details about the adult’s current account which you wish to access. This should be the

account which feeds your designated account.





Detail existing standing orders/direct debits set up on this account which you wish to cease or identify

those which you wish to set up on the above account.



Branch Name:

Number:

Street:

Locality:

City:

County:

Country:

Post Code:

Sort Code:

Name of Account Holder:

Account Number:

Name of Company to whom payment

Amount payable monthly £

is to be made for example, Scottish Power etc.

Cease:

Set Up:

ATF (6) 6 /17

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In addition to the adult’s current account, if you have authority to operate upon any other account in the

sole name of the adult and wish to continue this arrangement please identify the accounts below:

(You should note, if any account on which you have authority to operate is not identified below, your

authority will cease upon the new certificate being issued)

Use separate sheet if more accounts identified.



Branch Name:

Number:

Street:

Locality:

City:

County:

Country:

Post Code:

Sort Code:

Name of Account Holder:

Account Number:



Branch Name:

Number:

Street:

Locality:

City:

County:

Country:

Post Code:

Sort Code:

Name of Account Holder:

Account Number:

ATF (6) 7 /17



This section should be completed giving full details of all funds required. Please note that any original

funds authorised under your existing certificate which are not shown below will cease when your authority

to access the adult’s funds is renewed.

Before completing this section it is important to refer to the accompanying notes to complete this

application form. This will tell you how to calculate the anticipated expenditure and what supporting

evidence may be required.

Reason for Expenditure Monthly Amount £

Gas

Electricity

Telephone (inclusive of mobile phones and special telephone services)

Mortgage

Rent

Insurances (building, contents, motor, personal, pets etc)

Council Tax

TV Licence

Care Charges

Loan Repayments

Club or other subscriptions

Food and household expenses

Clothing

Holidays/Outings

Transport costs

Other (Please specify)



0.00

ATF (6) 8 /17

Section 2.5 - One off Lump Sum

The access to funds process not only allows for regular ongoing expenses to be taken but also allows for

a one off lump sum to be requested. This is generally used where there has been a build up of costs due

to the adult’s funds not being accessible and debts building up which require to be paid. A lump sum

payment may already have been authorised but in certain circumstances it may be possible for a further

single payment to be made. Before completing this section it is important to refer to the accompanying

notes to complete this application form. This will tell you what supporting evidence is required.

Do you require a lump sum?

If Yes, complete below If No, go to section 2.7

Section 2.6 – Account from which Lump Sum will be Transferred

If the lump sum requested is to be transferred from the adult’s current account please leave this section

blank, otherwise identify the account from which the lump sum is to be transferred.

Reason for Expenditure Amount £

One off payments/lump sums (Please specify)

TOTAL LUMP SUM £

Name of Bank/Building Society:

Branch Name:

Number:

Street:

Locality:

City:

County:

Country:

Post Code:

Sort Code:

Name of Account Holder:

Account Number:

0.00

ATF (6) 9 /17



A certificate of authority is normally valid for a period of three years. If you wish the certificate to be valid

for a period other than that you must state the period you require and the reason below:



If you propose to carry out any other additional financial transactions please provide details below:



Before the Public Guardian can proceed with this application there is a requirement to be satisfied that the

existing process is operating effectively. You must enclose with your application a copy of the pass book,

if issued, or the last two monthly bank or building society statements relating to the designated account.

Other documentation may be requested by the Public Guardian. Documents will be returned to you.

ATF (6) 10 /17





A copy of this application will be sent to the adult and other persons identified in the original application

and/or this application. If you consider that a copy of the application should not be sent to the adult as it

would pose a serious risk to the adult’s health please tick the box.

Simply to indicate that the adult would not understand the application or would be upset by it is not

sufficient grounds for non intimation.

If you have ticked the above box the Public Guardian will require you to lodge with this application a

medical certificate (in the form of SSI No 79) completed by two medical practitioners. A copy of form SSI

No 79 is enclosed.





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.

ATF (6) 11 /17

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



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 APPLICANT:

PRINT NAME:

DATE:

SIGNATURE OF ALL OTHER

IDENTIFIED WITHDRAWER(S):

PRINT NAME(S):

DATE:

The Public Guardian needs to confirm that the condition of the adult still meets the criteria as set in section

1(6) of the Act. The medical certificate (SSI No 76) enclosed at the rear of this form must now be completed

by a medical practitioner. You should arrange to have the medical certificate completed before you or the

countersignatory, if appropriate, sign and date this application.

Once completed this application must be lodged with the Public Guardian within 14 days of the applicant

and other withdrawers signing and dating the application form, or within 14 days of the countersignatory,

where appropriate, doing so.

Please note that where new joint withdrawers or a new reserve withdrawer is identified in this application

you require to have section 5 completed before lodging the application with this office. Section 5 does not

require to be completed where the application is made by an organisation.

ATF (6) 12 /17

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

This section only requires to be completed by a countersignatory where it is proposed to appoint a new

withdrawer not identified in the original application.

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. If there is more than one

withdrawer and you cannot find one countersignatory who meets the criteria for all you require a separate

countersignatory to support each applicant/withdrawer. Each countersignatory must fully complete a

separate section 5.

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

monetory 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 (6) 13 /17

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





• for at least one year prior to the signing of the foregoing application and I believe them to be a fit

and proper person(s) to intromit with the adult’s funds. I further believe that the information contained

in this application to be true.

• I am not :

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

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

relation to any matter under this Act; or

(d) the medical practitioner who has signed the medical certificate in connection with this 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 (6) 14 /17

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

possible.

Please comment below on how you feel that the applicant/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 (6) 15 /17

































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ATF (1) 17 /18

Scottish Statutory Instrument 2008 No. 51

(Previously SSI No. 76)

Regulation 3

Adults with Incapacity (Scotland) Act 2000 (“the Act”)

Certicate of incapacity to accompany an application to the Public Guardian under section

24C, 24D or 25

I ……………………………………………………............…………………...........…….……………....(Full Name)

of ……………………………………………….………………......................…….……..........................................

(Professional Address) in my capacity as .....................................................................................................

(1)

have examined the following patient on ……….…………...................................................……..……...(Date),

... ……………………………………………………..…............…..........………………………….(Patient’s Name)

of …………………................................................................................………………..…………………………..

…………………………..…………………….................…....(Address) ............./............/............ (Date of Birth)

I am of the opinion that he/she is incapable in relation to decisions about, or incapable of acting to

safeguard or promote his/her interests in, his/her funds.

I am of the opinion that the patient named above is incapable in terms of section 27B of the Act

because of:

mental disorder

(2)

and/or

inability to communicate because of physical disability

(3)

Brief description of mental disorder/inability to communicate ……….....................................………

……………………………………………………………………………....................................…………

……………………………………………………………………....................................…………………

(Signed) ……………….....................………………………..

(Date) ……………………….....................………………….

(1) the person signing the certicate must be a medical practitioner; insert as appropriate, eg GP,

specialist in mental disorder.

(2) mental disorder has the meaning given to it in section 328 of the Mental Health (Care and

Treatment) (Scotland) Act 2003, namely that it means any mental illness; personality disorder or

learning disability however caused or manifested, but an adult is not mentally disordered by reason

only of sexual orientation; sexual deviancy; transsexualism; transvestism; dependence on, or use

of, alcohol or drugs; behaviour that causes, or is likely to cause, harassment, alarm or distress to

any other person; or acting as no prudent person would act.

(3) one of these must be deleted unless both apply.

ATF (1) 18 /18

SCOTTISH STATUTORY INSTRUMENT 2001 No 79

Adults with Incapacity (Scotland) Act 2000 (“the Act”)

Evidence to inform decision to dispense with notication to adult with incapacity in terms of Sections 7(1)(d)

and 11(2) of the Act.

IMPORTANT: This form is to be completed by two medical practitioners.

A: First Medical Practitioner:

I ………………………………………………..........…………………………............……………..…....(Full Name)

of …………………………………………………………………...............…........…….......(Professional Address)

have examined the following patient on ……….…………….................................…..(Date), in my capacity as

…………………………………………………………………..........……..…..............………………………………*

to ……………….…………………………………………….............…………..........…………….(Patient’s Name)

…………………...........……(Date of Birth), of ………………………..……............………………….……………..

…………………………..…………………….…………….............…………….........………....(Patient’s Address)

I am of the opinion that it would pose a serious risk to the health of the patient named above for the Public

Guardian to notify him/her of an application under Section 26 of the Act for authority to intromit with funds.

The reason for this opinion is ……………………………...............................……………………………………...

……………………………………………………………...................................……………………………………...

………………………………………………….....….(Signed) …………..........…...................………………(Date)

B: Second Medical Practitioner:

I ………………………………………………………………………..........……............…………..…....(Full Name)

of ……………………………………………….…………...................................................(Professional Address)

have examined the following patient on ……….……………...…...................….….....(Date), in my capacity as

……………………………………………………..……………........……..............……………..……………………*

I am of the opinion that it would pose a serious risk to the health of the patient named above for the Public

Guardian to notify him/her of an application under Section 26 of the Act for authority to intromit with funds.

The reason for this opinion is…………………………………………......................………………...……………...

……………………………………………………………….........……………..............……………………………….

…………………………………………….………….(Signed) ………………..……................................…(Date)

* the person signing the certicate must be a medical practitioner; insert as appropriate, eg GP, specialist in

mental disorder

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