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Appointment Of Enduring Guardian Digital Form

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Enduring Guardianship

in New South Wales

APPOINTMENT OF ENDURING GUARDIAN FORM

Revised March 2018

Appointment of Enduring Guardian

For New South Wales

(Guardianship Regulation 2016, Schedule 1)

Important information to read before completing the

Enduring Guardianship appointment form

• AnEnduringGuardianshipappointmentisanimportantdocument.Itallows

someoneelsetomakemedicalandlifestyledecisionsonyourbehalf.Youshould

getlegalormedicaladvice(orboth)beforeyousignit.

• ItisimportantthatyoutrustthepersonyouappointasyourEnduringGuardian

tomakeappropriatelifestyledecisionsonyourbehalf.Itisrecommendedyou

informthispersonofyourwishesaboutlifestyledecisionsandinvolvethemin

discussionsaboutyourviewsorgoals.Ifthesechange,itisimportanttoletyour

EnduringGuardianknow.

• AnEnduringGuardiancanonlymakelifestyledecisionssuchashealthdecisions.

YoushouldmakeanEnduringPowerofAttorneyifyouwantsomeonetomake

nancialdecisionsonyourbehalfifyoulosecapacity.

• IfyouappointmorethanoneEnduringGuardian,youshouldindicatewhetherthe

EnduringGuardiansaretoactjointly,severallyorjointlyandseverally.Enduring

Guardianswhoareappointedjointlyareonlyabletomakedecisionsiftheyall

agreeaboutthedecision.EnduringGuardianswhoareappointedseverallyor

jointlyandseverallyareabletomakedecisionsindependentlyofeachother.

• IfyouappointasubstituteEnduringGuardian*,theywillonlyhaveauthorityto

actasyourguardianiftherstappointedenduringguardian/sdies,resignsor

becomesincapacitated.

• EachEnduringGuardianmustsigntheiracceptanceontheappointmentforitto

beeffective.

• Ifsomeonesignstheappointmentonyourbehalf,theymustbeatleast18years

old.TheymustnotbethepersonbeingappointedasanEnduringGuardian.

Theycannotalsowitnesstheexecutionoftheappointment.

• IfyoumarryafteryouappointanEnduringGuardianthentheappointmentwill

automaticallyberevoked(unlessyoumarriedyourEnduringGuardian).

•

YourEnduringGuardiancanresignatanytime,bygivingyounoticeinwriting.Ifyou

havelostcapacitytomakedecisionsatthattimethenyourEnduringGuardiancan

onlyresignwiththeapprovaloftheNSWCivil&AdministrativeTribunal.

• 

EnduringGuardianshipappointmentsarenotautomaticallyaccessibleonanypublic

theycancontacttheEnduringGuardianifrequired.Youshouldprovideacopyof

theEnduringGuardianshipappointmenttoyourEnduringGuardianandkeepacopy

inasafeplace.Youshouldalsoletclosefriendsorfamilyknowaboutitandgivea

copytoyoursolicitor,doctorandhealthserviceprovider.

• Furtherinformation:

TheOfceofthePublicGuardiancanprovideinformationonguardianship,

call 02 8688 6070.

NSWTrustee&GuardiancanprepareandwitnessyourEnduringGuardianship,

call 1300 364 103.

NSWCivil&AdministrativeTribunalGuardianshipDivisionshouldbecontacted

ifapersondoesnothavelegalcapacityorthereareconcernsaboutwhether

someonehadcapacitywhenanEnduringGuardianshiporPowerofAttorney

wasprepared,call1300 006 228.

*previouslyreferredtoasalternateguardian

EnduringGuardianshipAppointmentFormNewSouthWales  Page1of11

Appointment of Enduring Guardian

For New South Wales

(Guardianship Regulation 2016, Schedule 1)

1. Appointment of Enduring Guardian/s

I, [your full name]: __________________________________________________

Of [your address]: __________________________________________________

__________________________________________________________________

Occupation: _______________________________________________________

Phonenumber: ____________________________________________________

Dateofbirth: ______________________________________________________

Appoint [guardian’s name]: __________________________________________

Of[guardian’s address]: _____________________________________________

__________________________________________________________________

Phone number: ____________________________________________________

Occupation: _______________________________________________________

Appoint [guardian’s name]: __________________________________________

Of[guardian’s address]: _____________________________________________

__________________________________________________________________

Phonenumber: ____________________________________________________

Occupation: _______________________________________________________

Appoint [guardian’s name]: __________________________________________

Of[guardian’s address]: _____________________________________________

__________________________________________________________________

Phonenumber: ____________________________________________________

Occupation: _______________________________________________________

to be my Enduring Guardian/s.

2. Optional – substitute guardian

I appoint [substitute Enduring Guardian’s name]: ________________________

__________________________________________________________________

Of[address]: _______________________________________________________

__________________________________________________________________

Phonenumber: ____________________________________________________

Occupation: _______________________________________________________

to be my substitute Enduring Guardian.

Completeyourdetails

inthespaceprovided.

Appointor – Theperson

whomakesanEnduring

Guardianappointmentis

knownastheappointor.

Enduring Guardians –

Youmayappointoneor

morepeopletobeyour

EnduringGuardian/s.

Ifyouareappointingmore

thanoneEnduringGuardian

completedetailsforeach

guardian.

Note:anEnduring

Guardianmustbe18years

ofageandnothaveany

connectionwiththose

whoprovideyouwith

accommodation,health

careorservicesforafee.

Completethissectionifyou

wishtoappointasubstitute

guardian.

Asubstituteguardianis

someoneyouappointtobe

yourEnduringGuardianif

yourEnduringGuardian/s

dies,resignsorbecomes

incapacitated.

Note:Crossoutthissection

ifyoudonotwishtoappoint

asubstituteguardian.

EnduringGuardianshipAppointmentFormNewSouthWales  Page2of11

3. How I wish my Enduring Guardians to act

[Complete only if more than one Enduring Guardian has been appointed]

Ticktheapplicableboxbelowtoindicatewhetheryouareappointingyour

EnduringGuardianstoactjointly,severallyorjointlyandseverally.

Alsoindicatebytickingtheappropriateboxwhetheryouwantyourjointly/

jointlyandseverallyappointedEnduringGuardian/stocontinueintheirrole

intheeventofdeath,resignationorlossofcapacity.

3a) Joint appointment

IappointmyEnduringGuardianstoactjointlyand

[tick applicable box below]

IwanttheappointmenttobeterminatedifoneofmyEnduring

Guardiansdies,resignsorlosescapacity.

Idonotwanttheappointmenttobeterminatedifoneofmy

EnduringGuardiansdies,resignsorlosescapacity.

3b) Several appointment

IappointmyEnduringGuardianstoactseverally.

3c) Joint and several appointment

IappointmyEnduringGuardianstoactjointlyandseverallyand

[tick applicable box below]

Iwanttheappointmenttobeterminatedifoneofmy

EnduringGuardiansdies,resignsorlosescapacity.

Idonotwanttheappointmenttobeterminatedifoneof

myEnduringGuardiansdies,resignsorlosescapacity.

Tickapplicablebox/es

toindicatehowyouwish

yourEnduringGuardians

tomakedecisionsonyour

behalf.

Jointly

ThismeanstheEnduring

Guardiansmustagreeand

makealldecisionstogether.

Ifyouhaveappointedyour

EnduringGuardiansto

actjointlyyourEnduring

Guardianshipappointment

willautomaticallyterminate

ifoneofyourEnduring

Guardians dies, resigns or

becomesincapacitated.

Ifyoudonotwantthe

appointmenttoterminate

butwanttheremaining

EnduringGuardian/sto

continue in their role then

ticktheappropriatebox.

Severally

ThismeanstheEnduring

Guardianscanmake

decisionsseparately

ofeachother.

Ifyouhaveappointedyour

EnduringGuardianstoact

severallyyourEnduring

Guardianshipappointment

willautomaticallycontinue

ifoneofyourEnduring

Guardians dies, resigns or

becomesincapacitated.

Jointly and severally

ThismeanstheEnduring

Guardianscaneithermake

decisions together or

separately.

Ifyouhaveappointedyour

EnduringGuardianstoact

jointlyandseverallyyour

EnduringGuardianship

appointmentwill

automaticallycontinue

ifoneofyourEnduring

Guardians dies, resigns

orbecomesincapacitated.

Ifyoudonotwantthe

appointmenttocontinue

butwantittoterminatethen

ticktheappropriatebox.

EnduringGuardianshipAppointmentFormNewSouthWales Page3of11

4. Functions and limits of my Enduring Guardian/s

ShouldIbecomeincapableofmakingmyownpersonaldecisionsI

authorisemyEnduringGuardian/stoexercisethefollowingfunctions:

[tick any one or more boxes below]

 todecidewhereIlive

LimitsonauthorityofEnduringGuardian: ______________________________

__________________________________________________________________

 todecidewhathealthcareIreceive

LimitsonauthorityofEnduringGuardian: ______________________________

__________________________________________________________________

 todecidewhatotherkindsofpersonalservicesIreceive

LimitsonauthorityofEnduringGuardian: ______________________________

__________________________________________________________________

 toconsenttothecarryingoutofmedicalordentaltreatmentonme

(in accordance with Part 5 of the Guardianship Act 1987)

LimitsonauthorityofEnduringGuardian: ______________________________

__________________________________________________________________

 todecide:

__________________________________________________________________

EnduringGuardian/scan

onlymakehealthand

lifestyledecisions.You

shouldmakeanEnduring

PowerofAttorneyifyou

wantsomeonetomake

nancialdecisionsonyour

behalf.

Selectwhatfunctions

youwishyourEnduring

Guardian/stohaveshould

youlosecapacitytomake

decisionsyourself.

Youmayplacelimits

onthesefunctions.

Ifyouwishtoplacea

limitonthefunctionprovide

detailsinthespacebelow

eachfunction.

Note:

YourEnduringGuardian/s

canonlyexercisethese

functionsifyouhavelost

thecapacitytomake

decisionsyourself.

Youmayaddanyadditional

functionsyouwishyour

EnduringGuardian/sto

exerciseonyourbehalf.

Forexampleotherfunctions

couldinclude:

• access(makingdecisions

aboutwhoyoushould

havecontactwith).

• restrictivepractices

(decidingwhetherto

consenttotheuseof

physicalrestraintfora

limitedperiodtoprotect

youfromselfharm).

EnduringGuardianshipAppointmentFormNewSouthWales  Page4of11

5. Optional – directions to my Enduring Guardian/s

ThefunctionsofmyEnduringGuardian/smustbeexercisedinaccordance

withthefollowingdirections:

__________________________________________________________________

YoumaygiveyourEnduring

Guardian/sdirectionsabout

howyouwantthemtocarry

outtheirfunctions.

Forexample,youcandirect

themtoconsultotherfamily

membersbeforemaking

adecisionorgivedetails

aboutthekindofplaceyou

wouldliketoliveifyoulost

capacity.

Note:AnEnduring

Guardianmustexercise

theirfunctionsaccording

toanydirectionsyougive

them.

Youcanonlygivelawful

directions.Youcannotgive

directionstoyourEnduring

Guardian/stodosomething

whichisagainstthelaw.

Youmaywishtodirect

yourEnduringGuardianto

refertoyourAdvanceCare

Directivewhenmaking

medicalandhealthcare

decisions.

EnduringGuardianshipAppointmentFormNewSouthWales  Page5of11

6. Appointor’s signature and witness certiﬁcate

(Option – for Enduring Guardian signature/witness)

6a) My signature

Signature ___________________________ Date ________________________

6b) Optional – signature on my behalf

Theappointorinstructedmetosignthisappointmentontheirbehalf.

Signatureonbehalfofappointor _____________________________________

Date _____________________________________________________________

Signer’sfullname __________________________________________________

Signer’s address ___________________________________________________

Signer’sphonenumber: ____________________________________________

6c) Acceptance by Enduring Guardian

[Complete only if witnessed at the same time and by the same witness as

appointor. Cross out if this does not apply]

IacceptmyappointmentasEnduringGuardian.

Fullname _________________________________________________________

Signature ___________________________ Date ________________________

6d) My witness certicate

I, [your full name]: __________________________________________________

Of[your address]: __________________________________________________

Phonenumber: ____________________________________________________

Occupation:

 Australianlegalpractitioner

 RegistraroftheNSWLocalCourt

 Overseas-registeredforeignlawyer

 ApprovedemployeeofNSWTrustee&Guardian

Certify that [Tick applicable boxes below, cross out those which do not apply]

 Theappointorappearedtounderstandtheeffectofthisinstrument

andvoluntarilyexecutedtheinstrumentinmypresence.

 Theappointorvoluntarilyinstructed[insert signer’s full name]

_____________________________________________________________

 tosigntheinstrumentontheirbehalfandthatpersonexecutedthe

instrumentinmypresence.

_____________________________________________________________

[insert name of person accepting appointment as Enduring Guardian]

appearedtounderstandtheeffectofthisinstrumentandvoluntarily

executedtheinstrumentinmypresence.

Signature ___________________________ Date ________________________

You and your Enduring

Guardian can sign

this page at the same

time, in front of the

samewitness.

If your Enduring

Guardian’s signature

is witnessed at a

different time or by a

different witness, they

will need a separate

witness certicate.

Complete additional

signature and witness

certicate pages.

Note:

Beforeyousignhere

youmustarrangefora

witnesstowatchyou

signthisappointment

andcertifythatyou

appear to understand this

appointment.Yourwitness

needstocompletetheir

detailsinsection6d)below.

Ifyouarephysicallyunable

tosignasktheperson

signingforyoutosign

andcompletetheirdetails

opposite.Thepersonmust

beover18yearsandmust

notbethepersonbeing

appointedorthewitnessas

describedbelow.

Thewitnesscannotbe

theEnduringGuardian,

orasubstituteEnduring

Guardian.

Thewitnessmustbean

Australianlegalpractitioner/

RegistraroftheNSW

LocalCourt/overseas-

registeredforeignlawyer

orapprovedemployeeof

NSWTrustee&Guardian.

Onlythesepersonscan

witnesstheexecutionof

thisappointment.

EachEnduringGuardian

mustsigntheiracceptance

ontheappointmentforitto

beeffective.

IMPORTANT Refer to checklist before completing this section

EnduringGuardianshipAppointmentFormNewSouthWales  Page6of11

7. Optional – substitute Enduring Guardian’s

acceptance and witness certiﬁcate

7a) Acceptance by substitute Enduring Guardian

[Complete only if substitute Enduring Guardian appointed]

IacceptmyappointmentasEnduringGuardian.

Fullname _________________________________________________________

Signature ___________________________ Date ________________________

7b) Substitute Enduring Guardian’s witness certicate

I, [full name]: _______________________________________________________

Of[address]: _______________________________________________________

__________________________________________________________________

Phonenumber: ____________________________________________________

Occupation:

 Australianlegalpractitioner

 RegistraroftheNSWLocalCourt

 Overseas-registeredforeignlawyer

 ApprovedemployeeofNSWTrustee&Guardian

Certify that _______________________________________________________

[insert name of person accepting appointment as substitute Enduring

Guardian]

appearedtounderstandtheeffectofthisinstrumentandvoluntarily

executedtheinstrumentinmypresence.

Signature ___________________________ Date ________________________

Note:

Beforethesubstitute

EnduringGuardiansigns

heretheymustarrangefor

awitnesstowatchthem

signthisform.Thewitness

needstocompletetheir

detailsinsection7b)below.

Thewitnesscannotbe

theEnduringGuardian,

orasubstituteEnduring

Guardian/s.

Thewitnessmustbean

Australianlegalpractitioner/

RegistraroftheNSW

LocalCourt/overseas-

registeredforeignlawyer

orapprovedemployeeof

NSWTrustee&Guardian.

Onlythesepersonscan

witnesstheexecutionof

thisappointment.

EnduringGuardianshipAppointmentFormNewSouthWales  Page7of11

8. Enduring Guardian’s acceptance and witness

certiﬁcate

8a) Acceptance by Enduring Guardian

[Cross out if Enduring Guardian has already signed and Enduring Guardian’s

witness certicate has been completed]

IacceptmyappointmentasEnduringGuardian.

Fullname _________________________________________________________

Signature ___________________________ Date ________________________

8b) Enduring Guardian’s witness certicate

I, [full name]: ________________________________________________________

Of[address]: ________________________________________________________

___________________________________________________________________

Phonenumber: _____________________________________________________

Occupation:

 Australianlegalpractitioner

 RegistraroftheNSWLocalCourt

 Overseas-registeredforeignlawyer

 ApprovedemployeeofNSWTrustee&Guardian

Certify that _______________________________________________________

[insert name of person accepting appointment as Enduring Guardian]

appearedtounderstandtheeffectofthisinstrumentandvoluntarily

executedtheinstrumentinmypresence.

Signature ___________________________ Date ________________________

Note:

BeforetheEnduring

Guardiansignsherethey

mustarrangeforawitness

towatchthemsignthis

form.Thewitnessneeds

tocompletetheirdetails

insection8b)below.

Thewitnesscannotbe

theEnduringGuardian,

orasubstituteEnduring

Guardian/s.

Thewitnessmustbean

Australianlegalpractitioner/

RegistraroftheNSW

LocalCourt/overseas-

registeredforeignlawyer

orapprovedemployeeof

NSWTrustee&Guardian.

Onlythesepersonscan

witnesstheexecutionof

thisappointment.

YourEnduringGuardian/s

canresignatanytime

bygivingyounoticein

writing.Ifyouhavelost

capacityatthattime,then

yourEnduringGuardian/s

canonlyresignwiththe

approvaloftheNSWCivil&

AdministrativeTribunal.

EnduringGuardianshipAppointmentFormNewSouthWales  Page8of11

9. Additional Enduring Guardian’s signature and

witness certiﬁcate/s

[Cross out if Enduring Guardian has already signed and Enduring Guardian’s

witness certicate has been completed]

9a) Acceptance by Enduring Guardian

IacceptmyappointmentasEnduringGuardian.

Fullname _________________________________________________________

Signature ___________________________ Date ________________________

9b) Enduring Guardian’s witness certicate

[Cross out if Enduring Guardian’s signature already witnessed]

I, [full name]: _______________________________________________________

Of [address]: _______________________________________________________

__________________________________________________________________

Phonenumber: ____________________________________________________

Occupation:

 Australianlegalpractitioner

 RegistraroftheNSWLocalCourt

 Overseas-registeredforeignlawyer

 ApprovedemployeeofNSWTrustee&Guardian

Certify that _______________________________________________________

[insert name of person accepting appointment as Enduring Guardian]

appearedtounderstandtheeffectofthisinstrumentandvoluntarily

executedtheinstrumentinmypresence.

Signature ___________________________ Date ________________________

Note:

Beforeyousignhereyou

mustarrangeforawitness

towatchyousignthis

form.Thewitnessneeds

tocompletetheirdetailsin

section9b)below.

Thewitnessescannot

betheEnduringGuardian,

orasubstituteEnduring

Guardian/s.

Thewitnessmustbean

Australianlegalpractitioner/

RegistraroftheNSW

LocalCourt/overseas-

registeredforeignlawyer

orapprovedemployeeof

NSWTrustee&Guardian.

Onlythesepersonscan

witnesstheexecutionof

thisappointment.

EnduringGuardianshipAppointmentFormNewSouthWales  Page9of11

9aa) Acceptance by Enduring Guardian

[Cross out if Enduring Guardian has already signed and Enduring Guardian’s

witness certicate has been completed]

IacceptmyappointmentasEnduringGuardian.

Fullname _________________________________________________________

Signature ___________________________ Date ________________________

9bb) Additional Enduring Guardian’s witness certicate

[Cross out if Enduring Guardian’s signature already witnessed]

I, [full name]: _______________________________________________________

Of[address]: _______________________________________________________

__________________________________________________________________

Phonenumber: ____________________________________________________

Occupation:

 Australianlegalpractitioner

 RegistraroftheNSWLocalCourt

 Overseas-registeredforeignlawyer

 ApprovedemployeeofNSWTrustee&Guardian

Certify that _______________________________________________________

[insert name of person accepting appointment as Enduring Guardian]

appearedtounderstandtheeffectofthisinstrumentandvoluntarily

executedtheinstrumentinmypresence.

Signature ___________________________ Date ________________________

Note:

Beforeyousignhereyou

mustarrangeforawitness

towatchyousignthis

form.Thewitnessneeds

tocompletetheirdetailsin

section9bb)below.

Thewitnessescannot

betheEnduringGuardian,

orasubstituteEnduring

Guardian/s.

Thewitnessmustbean

Australianlegalpractitioner/

RegistraroftheNSW

LocalCourt/overseas-

registeredforeignlawyer

orapprovedemployeeof

NSWTrustee&Guardian.

Onlythesepersonscan

witnesstheexecutionof

thisappointment.

EnduringGuardianshipAppointmentFormNewSouthWales  Page10of11

Enduring Guardianship Checklist

CheCklist

Please read below and tick to ensure you have completed all details of your Enduring

Guardianshipappointment correctly.

1. IhavespokentomyproposedEnduringGuardian/sanddiscussedthis

appointmentwiththemtoensuretheyarewillingandabletotakeonthisrole

andexercisethefunctionsIwishtogivethemasdescribedinsections3and4.

2. ItrustmyEnduringGuardian/sandhavespokentothemaboutthekindof

lifestyledecisionsIwishthemtomakeonmybehalfshouldIlosecapacity.

Ifthesechange,IunderstanditisimportanttoletmyEnduringGuardian/sknow.

3. IhavediscussedtheappointmentofmyEnduringGuardian/swithmyclose

friends/familytoletthemknowofmydecisiontoappointanEnduringGuardian.

4. Ihaveconsideredtheoptioninsection2ofappointingasubstituteguardian

shouldmyrstappointedEnduringGuardiandie,resignorbecome

incapacitated.

5. IhaveindicatedhowIwishmyEnduringGuardianstoact(i.e.jointly,severallyor

jointlyandseverally)bycompletingsection3.

6. IunderstandIcanasksomeonetosignthisappointmentonmybehalfin

section6ifIamphysicallyunabletosign.Thispersonmustbeovertheageof

18andcannotbemyEnduringGuardian/sorawitnesstothisappointment.

7. Iunderstandthecerticateofwitnessneedstobecompletedbyaneligible

witness,i.e.anAustralianlegalpractitioner/RegistraroftheNSWLocalCourt/

overseas-registeredforeignlawyerorapprovedemployeeofNSWTrustee

&Guardian.

8. IunderstandmyEnduringGuardian/sneedtosigntheiracceptanceofthe

EnduringGuardianappointmentbeforeitcanoperate.

9. IunderstanditisimportanttogiveacopyofthisEnduringGuardianship

appointmenttomyEnduringGuardian/sandotherrelevantpeople,suchas

myGPandattorney,andIwillkeepacopyinasafeplace.Thereisnopublic

10.IunderstandthatifImarry,theEnduringGuardianshipappointmentwillbe

revokedunlessIammarryingmyEnduringGuardian.

11.Iunderstanditisadvisabletogetmedicalandlegaladvicebeforesigning

myEnduringGuardianshipappointment.

EnduringGuardianshipAppointmentFormNewSouthWales  Page11of11

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Completed 27 May 2020

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