ADULTS WITH INCAPACITY
(SCOTLAND) ACT 2000
Transition of Authority
ATF(7)
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(6) - Renewal of Authority
Other application forms
available in this series:
3
Notes to complete
this Form
This form should only be used where there is a financial guardian in terms of
Part 6 of the Adults with Incapacity (Scotland) Act 2000 and you wish to apply
for recall of that guardianship in favour of an application for access to funds
where:
(a) the guardian proposes to become the withdrawer, or
(b) someone other than the guardian proposes to become the 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.
Provided the Public Guardian is satisfied that the adult’s property and
financial affairs can be safeguarded or promoted other than by guardianship,
an application for access to funds may be granted once the guardianship is
recalled. The former financial guardian or any other person may apply to be the
withdrawer.
Section 1 relates to the recall of the powers of the financial guardian
and requests details of the existing authority and details of any
disagreement identified after consultation with appropriate
interested parties to the guardianship. The financial guardian
must sign and date this section.
Section 2 requests details of the proposed withdrawer and
details of any identified joint/reserve withdrawers. In section
2.1 – Details of the proposed withdrawer: individual(s)
should complete the part marked (Individuals Only)
while organisations should complete the part
marked (Organisations Only).
Where personal
details of interested
parties have
changed this should
be shown in sections
2.5 to 2.9 of the
application form.
4
Since an application for guardianship has been previously granted relating
to the same adult there is no requirement to duplicate details of the adult
or other interested parties, for example, nearest relative, primary carer etc.
However, where personal details of such persons have changed this should
be shown in sections 2.4 to 2.9 of the application form.
If the guardianship has been in existence for some time the applicant should
provide full details to ensure that the Public Guardian’s records accurately
reflect the position.
Section 3 requests financial information. The applicant must identify the
account which is to be used as the current account in section 3.1 and confirm
any direct debits/standing orders which are to remain on this account in
section 3.2. Failure to do the latter will result in existing direct debits/standing
orders on that account being stopped once the certificate is lodged with the
bank/building society. A second account, if in existence, should be identified
in section 3.3.
In section 3.4 the applicant must identify the anticipated ongoing monthly
expenditure required to meet the adult’s financial needs and complete
the section appropriately. Banks/Building Societies etc normally deal with
financial matters in monthly periods consequently this is the period considered
as best suited in this application form. Care costs are sometimes calculated in
four weekly periods so some adjustment would be required. If, however, this
does not suit the adult’s particular needs you may wish to discuss this with
staff at this office.
Identifying on-going expenditure is a reasonably straightforward process
similar to that probably used in your own household budgeting. The aim is to
ensure that the day to day and on-going living expenses can be paid from the
income/funds held in the account and/or savings.
This section of the form is designed in a way that it covers most of the normal
monthly costs such as utility bills, mortgage or rent, council tax etc. There
is also a part for any other expenditure under the heading “other - please
specify”. It is not always possible to have a distinct heading for every
eventuality and where an expected expenditure does not fit into the categories
shown it should be identified as other and needs to be specified, eg personal
spending money. Use the examples provided below as a guide to completion
of this part of the form.
5
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.
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.
As indicated above the amounts requested do not need to be exact but it
is important to ensure that there will be sufficient money in the designated
account to make sure the adult is provided for by using his or her funds. Over
estimating, within reason, will not be seen as detrimental to the adult. The
Public Guardian may request to see some form of evidence of anticipated
expenditure, for example, utility bills, care home invoices etc as part of the
application process.
The Public Guardian may apply a degree of flexibility in that anything which
is seen to be reasonable and appropriate does not necessarily have to be
supported by invoice or other form of evidence. However, the Public Guardian
reserves the right to request further information or evidence when considering
an application.
The access to funds process also allows a one off lump sum to be requested.
This should be identified at section 3.5 if required. This is generally used
where there has been a build up of costs due to the account not being
accessible and debts building up which require to be paid. The example
shown over demonstrates how this can be done.
Remember to build
in a gure in your
calculations to cover
ination as shown in the
examples opposite.
6
Example: An adult may have been in a home for a period of four months
before the application is considered. If the care home costs were £2,000 per
month this would build up a debt due of some £8,000 (£2,000 x 4 months).
It normally takes four weeks to fully process an application to access funds
therefore you should also request a further £2,000 to cover the debt which will
continue to accrue until the certificate of authority is issued allowing you to
pay off this debt. Therefore the lump sum request in this example should be
£10,000.
The cost of the application and any costs associated with obtaining the
medical certificates may be identified as part of the lump sum and can then
be reimbursed through the designated account once the lump sum is
paid therein.
A lump sum request might look as follows:
Outstanding care costs £10,000
Underpayment of council tax £ 250
Medical certificate from Doctor £ 100
OPG registration fee £ 60
Total Lump Sum request £10,410
Generally where a lump sum is requested the Public Guardian will expect to
see evidence of its purpose in the form of an invoice or similar. In the example
shown above the Public Guardian would expect to see an invoice relative to
the outstanding care costs; council tax and the doctor’s fee note.
The period of authority is normally set at three years but may be extended or
reduced 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 3.7 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 3.8 of the application form.
Section 4 identifies that a copy of the application will be sent to the adult and
other persons named in the original and/or in the application.
7
Because the adult
cannot read or
understand the content
of a document does
not constitute or pose a
serious risk to health.
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 No 79
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 5 contains an undertaking and declaration which all
withdrawers require to sign and date. Where the proposed
withdrawer is not the previous guardian section 6 requires
to be completed.
Section 6 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. 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
No 76 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. The section Medical Certificates in the
guidance notes for access to funds provides further information.
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 (7) 1 /22
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

I hereby apply for the financial powers in the guardianship order to be recalled because another less
intrusive measure other than guardianship, namely access to funds scheme, could satisfactorily safeguard
the interests of the adult.

In making this decision I have consulted the adult; primary carer; nearest relative and all other persons
that the sheriff has said must be consulted. They agree/disagree (delete as appropriate) to the proposed
action. Where there is a disagreement please specify the reason and by whom below:
SIGNATURE OF GUARDIAN FOR RECALL:
PRINT NAME:
DATE:
ADULTS WITH INCAPACITY



ATF (7) 2 /22

Where more than one withdrawer is proposed, details should be identified in section 2.2 as joint
withdrawers.
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)
Please answer the following questions deleting YES or NO as appropriate and follow the instructions given.
Is the proposed withdrawer the:
Nearest Relative If No complete Section 2.5
Primary Carer If No complete Section 2.6
Named Person If No complete Section 2.7
Attorney/Guardian If No complete Section 2.8

Is it intended that the current guardian be the withdrawer?
If Yes, go to section 2.2 If No, complete section 2.1
ATF (7) 3 /22

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:
ATF (7) 4 /22
Use separate page if necessary.
Please identify relationship to the adult: (If family member please state exact relationship)
Please answer the following questions deleting YES or NO as appropriate and follow the instructions given.
Is the proposed withdrawer the:
No 1 No 2
Nearest Relative If No complete Section 2.5
Primary Carer If No complete Section 2.6
Named Person If No complete Section 2.7
Attorney/Guardian If No complete Section 2.8

Is it intended that there be joint withdrawer(s)?
If Yes, complete below If No, go to section 2.3
Joint Withdrawer (1) Joint Withdrawer (2)
Title:
Surname:
Forename:
Middle Name:
House Name:
House Number:
Street:
Locality:
City:
County:
Country:
Post Code:
Tel No:
E-Mail Address:
ATF (7) 5 /22
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)

In the guardianship order made by the court the adult’s details were provided. There is no requirement to
provide this information again, however, if for any reason, their details have changed for example, change
address, and the Public Guardian has not been notified please advise changes below:


Is it intended that a reserve withdrawer be identified at this time? 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 2.4
ATF (7) 6 /22

The nearest relative of the adult may be a spouse, brother, sister, son or daughter of the adult or some
other more distant relative. If the applicant is the nearest relative there is no need to complete this section.
In certain circumstances any person claiming an interest on behalf of an adult with incapacity may ask a
sheriff to make an order which will stop certain information being given to the nearest relative. In making
such an order, the sheriff will have named another person to act as the nearest relative. This will only be for
the purpose of any application made in terms of this Act. This person may be another relative for example,
a nephew or niece or somebody else such as a friend or neighbour.
In the guardianship order made by the court the nearest relative’s details may have been
provided. You are not required to complete this section unless the details of the nearest
relative have changed.
Title:
Surname:
Forename:
Middle Name:
House Name:
House Number:
Street:
Locality:
City:
County:
Country:
Post Code:
Tel No:
E-Mail Address:
If there has been a Court Order naming the above as the nearest relative to the adult please tick this box
Please answer the following questions deleting YES or NO as appropriate and follow the instructions given.
Is the nearest relative the:
Primary Carer If No complete Section 2.6
Named Person If No complete Section 2.7
Attorney/Guardian If No complete Section 2.8
ATF (7) 7 /22
Title:
Surname:
Forename:
Middle Name:
Name of Organisation: (if applicable)
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)
Please answer the following questions deleting YES or NO as appropriate and follow the instructions given.
Is the primary carer the:

The primary carer is the person who has day to day responsibility to look after the needs of the adult.
If the adult is in hospital or a care home etc you should identify the primary carer as being the manager or
officer in charge of the ward, care home or other establishment.
In the guardianship order made by the court the primary carer’s details may have been
provided. You are not required to complete this section unless the details of the primary
carer have changed.
Named Person If No complete Section 2.7
Attorney/Guardian If No complete Section 2.8
ATF (7) 8 /22

A named person is someone who, in terms of the Mental Health (Care and Treatment)(Scotland) Act 2003,
has powers and rights to represent and safeguard the adult’s interests.
In the guardianship order made by the court the named person’s details may have been provided. You
are not required to complete this section unless the details of the named person have changed.
Does the adult have a named person?
If Yes, complete below If No or not known, go to section 2.8
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)
Please answer the following question deleting YES or NO as appropriate and follow the instructions given.
Is the named person the:
Attorney/Guardian If No complete Section 2.8
ATF (7) 9 /22

A continuing attorney includes a reference to a person granted, under a contract, grant or appointment
governed by the law of any country, powers (however expressed) relating to the granter’s property or
financial affairs and having continuing effect notwithstanding the granter’s incapacity.
A welfare attorney includes a reference to a person granted, under a contract, grant or appointment
governed by the law of any country, powers (however expressed) relating to the granter’s personal welfare
and having effect during the granter’s incapacity.
Guardian includes a reference to a guardian (however called) appointed under the law of any country to,
or entitled under the law of any country to act for, an adult during his incapacity, if the guardianship is
recognised by the law of Scotland.
In the guardianship order made by the court the attorney or guardian’s details may have been provided.
You are not required to complete this section unless the details of the attorney or guardian have
changed.
Does the adult have an attorney or guardian?
If Yes, complete below If No or not known, go to section 2.9
Title:
Surname:
Forename:
Middle Name:
House Name:
House Number:
Street:
Locality:
City:
County:
Country:
Post Code:
Tel No:
E-Mail Address:
ATF (7) 10 /22

Any other interested party is any other person who has not already been identified in the application and
who has an interest in the adult’s affairs. This may be other relatives or partners.
In the guardianship order made by the court the details of any interested parties may have been
provided. You are not required to complete this section unless such details have changed.
Use separate page if necessary.
Title:
Surname:
Forename:
Middle Name:
House Name:
House Number:
Street:
Locality:
City:
County:
Country:
Post Code:
Tel No:
E-Mail Address:
Title:
Surname:
Forename:
Middle Name:
House Name:
House Number:
Street:
Locality:
City:
County:
Country:
Post Code:
Tel No:
E-Mail Address:
Now go to Section 3
ATF (7) 11 /22

Branch Name:
Number:
Street:
Locality:
City:
County:
Country:
Post Code:
Sort Code:
Name of Account Holder:
Account Number:


Please provide full details about the adult’s existing account which you wish to access. This account will be
referred to as the adult’s current account.


Detail existing standing orders/direct debits set up on this account which you wish to continue or identify
those which you wish to set up on this account. Please note that any existing standing orders/direct debits
on this account not identified here will cease to be paid when you commence to access the adult’s funds.

In addition to the adult’s current account it is possible to identify an existing account in the adult’s sole
name which will be known and operated as the adult’s second account. It may be that some funds would
benefit from being placed into this second account.
Name of Company to whom payment
Amount payable monthly £
is to be made for example, Scottish Power etc.
Continue:
Set Up:
ATF (7) 12 /22
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)

If the adult already has a bank account in his/her sole name which you would wish to operate as a second
account provide details below:

This section should be completed giving full details of all funds required.
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.

Branch Name:
Number:
Street:
Locality:
City:
County:
Country:
Post Code:
Sort Code:
Name of Account Holder:
Account Number:
0.00
ATF (7) 13 /22

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. 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 3.7
Reason for Expenditure Amount £
One off payments/lump sums (Please specify)


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.

Branch Name:
Number:
Street:
Locality:
City:
County:
Country:
Post Code:
Sort Code:
Name of Account Holder:
Account Number:
0.00
ATF (7) 14 /22

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:
ATF (7) 15 /22


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) open a 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 (7) 16 /22


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 PROPOSED
WITHDRAWER:
PRINT NAME:
DATE:
SIGNATURE OF ANY OTHER
PROPOSED 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 (SSI76) enclosed at the rear of this form must now be completed by
a medical practitioner and accompany your application. 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 proposed
withdrawer and any other withdrawers signing and dating the application form.
Please note that where joint withdrawers or a new reserve withdrawer are identified in this application you
require to have section 6 completed before lodging the application with this office.
ATF (7) 17 /22

This section does not require to be completed where the guardian applying for recall of powers is to be
the withdrawer.
The countersignatory must read the full application form and agree to its content and be satisfied that this
application 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 are new joint
withdrawers/reserve withdrawer and you cannot find one countersignatory who meets the criteria for all
you require a separate countersignatory to support each withdrawer. Each countersignatory must fully
complete a separate section 6.
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 a “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 (7) 18 /22



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 (7) 19 /22
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 (7) 20 /22














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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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