ADULTS WITH INCAPACITY
(SCOTLAND) ACT 2000
Renewal of Authority
ATF(6)
Notes to complete
Application Form
OFFICE OF THE PUBLIC GUARDIAN (SCOTLAND)
2
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:
3
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.
4
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.
5
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.
6
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.
7
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

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
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

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
(c) a solicitor acting on behalf of the adult or any other person mentioned in this sub-paragraph in
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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