ADULTS WITH INCAPACITY
(SCOTLAND) ACT 2000
Additional Joint
Withdrawer(s) ATF(3)
Notes to complete
Application Form
OFFICE OF THE PUBLIC GUARDIAN (SCOTLAND)
2
Notes to complete
this Form
This form should only be used where an access to funds is already in place and
additional joint withdrawers require to be appointed. The application should
be made by the person wishing to become the joint withdrawer. The existing
withdrawer(s) must be in agreement with the proposed appointment otherwise
the application cannot be approved.
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 and
personal details of the applicants to become 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 Office of the Public Guardian.
Section 2 contains an undertaking and declaration which must be
read carefully by the applicant(s) who should all sign and date the
application form. The existing withdrawer(s) must also sign and date the
form to confirm their agreement to the application.
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.
Where personal
details of any
interested party to
the application have
changed this should
be shown in section
1.3 of the application
form.
3
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.
Remember the time
restriction for lodging
your application. It is
shown opposite.
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 (3) 1 /7


The information required below can be obtained from the existing withdrawer’s certificate of authority.


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
If there are more than 2 applying please use separate page.
Proposed Withdrawer (1) Proposed Withdrawer (2)
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)
ADULTS WITH INCAPACITY



ATF (3) 2 /7

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
identified in the original application, unless notified otherwise. This is to allow them the
opportunity to make comment, or indeed to object, if they wish, to your proposals. This is
a requirement of the legislation.
ATF (3) 3 /7


I understand that it is my responsibility to keep records of the exercise of my powers as withdrawer and to
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 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(S):
PRINT NAME(S):
DATE:
SIGNATURE OF ALL PROPOSED
JOINT WITHDRAWER(S):
PRINT NAME(S):
DATE:
Once completed you should arrange for the countersigning officer to read the document
and complete section 3. The application must be lodged with the Public Guardian within
14 days of the countersignatory signing and dating the application form.
ATF (3) 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. In this application, if there are
joint withdrawers and you cannot find one countersignatory who meets the criteria for all, you require a
separate countersignatory to support each withdrawer. Each countersignatory must complete a separate
section 3.
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 (3) 5 /7



for at least one year prior to the signing of the foregoing application and I believe the proposed
withdrawer(s) 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 (3) 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 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 (3) 7 /7
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
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
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