ADULTS WITH INCAPACITY - (SCOTLAND) ACT 2000
Application form
Request account information ATF (1) (Version 2)
Individual(s)
Please refer to the guidance notes to assist with completion
Section 1 - Personal information
Section 1.1 - Current details of the adult
Title House/no
Forename Street
Middle name Locality
Surname City
Date of birth County
Tel no Country
E-mail address Post code
Ethnic origin
(Please tick as appropriate)
White Scottish Other White British White Irish
Other White Indian Pakistani
Bangladeshi Other (South Asian) Chinese
Caribbean
African Black Scottish and Other Black
Mixed Other
A copy of this application will be sent to the person named above, if you consider this should not
be sent as it would pose a serious risk to their health please tick the box.
By ticking this box you are required to lodge the enclosed SSI No 79 medical certificate with the
application. This must be completed by two registered and licensed medical practitioners, one of whom
must be a specialist under the terms of the Mental Health Care & Treatment Act.
SIMPLY TO INDICATE THAT THEY WOULD NOT UNDERSTAND THE APPLICATION OR WOULD
BE UPSET BY IT IS NOT SUFFICIENT GROUNDS FOR NON-INTIMATION.
Page 1 of 16
Section 1.2 - Details of applicant(s)
Applicant 1
Title House/no
Forename Street
Middle name Locality
Surname City
Tel no County
E-mail address Country
Relationship (e.g. spouse, son, friend, professional etc.) Post code
Applicant 2
Title House/no
Forename Street
Middle name Locality
Surname City
Tel no County
E-mail address Country
Relationship (e.g. spouse, son, friend, professional etc.) Post code
if there are more than two applicants, please continue on a separate page
Section 1.3 - Details of the nearest relative
Title House/no
Forename Street
Middle name Locality
Surname City
Tel no County
E-mail address Country
Relationship (e.g. spouse, son, sister, cousin etc.) Post code
If there has been a court order naming the above as the nearest relative please tick this box.
Page 2 of 16
Section 1.4 - Details of the primary carer
Title House/no
Forename Street
Middle name Locality
Surname City
Tel no County
E-mail address Country
Relationship (e.g. spouse, son, friend, professional etc.) Post code
Section 1.5 - Details of any named person, attorney, intervener or guardian
Title House/no
Forename Street
Middle name Locality
Surname City
Tel no County
E-mail address Country
Relationship (e.g. spouse, son, friend, professional etc.) Post code
Please indicate role
Named person
attorney intervener guardian
if more than one role applies please continue on a separate page
Page 3 of 16
Section 1.6 - Details of any interested parties
e.g. other family members, friend, advocate etc.
Title House/no
Forename Street
Middle name Locality
Surname City
Tel no County
E-mail address Country
Relationship (e.g. spouse, son, friend, professional etc.) Post code
Page 4 of 16
Title House/no
Forename Street
Middle name Locality
Surname City
Tel no County
E-mail address Country
Relationship (e.g. spouse, son, friend, professional etc.) Post code
Title House/no
Forename Street
Middle name Locality
Surname City
Tel no County
E-mail address Country
Relationship (e.g. spouse, son, friend, professional etc.) Post code
Title House/no
Forename Street
Middle name Locality
Surname City
Tel no County
E-mail address Country
Relationship (e.g. spouse, son, friend, professional etc.) Post code
Section 2 - Financial information
Section 2.1 - Existence of an account
Please only complete this section when the sort code and account number are known
Bank/Building Society
Branch name
No/building
Street
Locality
City
County
Country
Post code
Sort code
Account holder
Account number
Bank/Building Society
Branch name
No/building
Street
Locality
City
County
Country
Post code
Sort code
Account holder
Account number
Page 5 of 16
Please continue on a separate page if necessary
BLANK FOR ADMIN PURPOSES - DO NOT REMOVE
Page 6 of 16
Section 2.2 - Need to identify what accounts exist
Abbey TSB Scotland
Alliance & Leicester Nationwide Building Society
Barclays Nat West Bank
Bradford & Bingley
Northern Rock
Cheltenham & Gloucester Royal Bank of Scotland
Clydesdale Bank
Santander
Dunfermline Building Society Standard Life Bank
Halifax/Bank of Scotland Woolwich
HSBC Yorkshire Building Society
Lloyds TSB Others: (Please specify)
Section 2.3 - Indicative use of funds
Likely need for expenditure Estimated monthly amount £
Gas
Electricity
Telephone
Mortgage
Rent
Insurances
Council tax
TV licence
Care charges
Loan repayments
Club or other subscriptions
Food and household expenses
Clothing
Holidays/outings
Personal allowance
Gifts
Other (please specify)
One off payments/lump sum (please specify)
Page 7 of 16
Section 2.4 - Additional information
Additional information to support your application e.g. background
Page 8 of 16
Section 3 - Terms of declaration
You are required to read over and sign the declaration and data protection/use of information
statement below.
Declaration
zI believe that it is appropriate for me to make this application;
zI believe that funds are held in the sole name of the adult as identified;
zI believe the information contained in this application to be true;
zI declare that the information is requested for the sole purpose of progressing an application to
access the funds of the adult in terms of Part 3 of the Adults with Incapacity (Scotland) Act 2000 as
amended;
zI understand that accessing this information for any other purpose is considered a breach of
confidentiality; and
zI understand that information disclosed by banks/building societies etc. is confidential and any
breach of this by me may result in legal action.
Data protection/use of information
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 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 applicants
Print name(s)
Date
Page 9 of 16
Section 4 - Countersignatory information
Title
Forename
Middle name
Surname
House/no
Street
Locality
City
County
Country
Post code
Tel no
Email address
Relationship to applicants(s)
(e.g. friend, neighbour, colleague)
Declaration of countersignatory
I declare that I have known
(insert name(s) above)
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 applicant(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 appication; 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.
Page 10 of 16
Delete (a) or (b below
a) I have no pecuniary interest in this application.
b)
I have a pecuniary interest in this application.
The nature and extent of the interest is:
The countersignatory must now answer the question below providing as much relevant information as
possible.
Signature of countersignatory
Print name
Date
THE APPLICATION MUST BE LODGED WITHIN 14 DAYS OF THIS DATE.
Page 11 of 16
Please comment below on how you feel that the applicant is a fit and proper person and has the ability to
carrry out the functions of withdrawer:
Checklist for applicant:
Have you completed all the relevant sections?
Have all applicant(s) signed and dated the form?
Has the form been countersigned and dated?
Is the application form being submitted within 14 days of the date it was signed by the
countersignatory?
Where appropriate, have medical certificate(s) been completed and enclosed?
Where appropriate have you enclosed relevant fee?
Please see our website for current fees or telephone us.
Cheques should be made payable to the 'Scottish Courts & Tribunals Service'.
Alternatively you may pay by debit card prior to posting your application.
If you wish to pay by BACS please ensure you quote 'ATF' and the adult's surname as a reference,
please also mention the fee is being paid by this method in your cover letter. Our bank account number
is 00650476 sort code 83-20-32.
Please print, sign and send to:
Office of the Public Guardian (Scotland)
Hadrian House
Callendar Business Park
Callendar Road
FALKIRK
FK1 1XR
DX: 550360 Falkirk 3
Telephone: 01324 677140
Website: www.publicguardian-scotland.gov.uk
Email: OPGATF@scotcourts.gov.uk
Twitter: @OPGScotland
Page 12 of 16
It is advisable to have the application and enclosures weighed at the Post Office to ensure that the
correct postage is applied.
Pr
int Form Reset Form
Scottish Statutory Instrument 2008 No. 51
Adults with Incapacity (Scotland) Act 2000 ("the Act")
Regulation 3
Certificate 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, the 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 certificate must be a registered and licenced medical practitioner; insert as
appropriate, e.g. 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
(3) 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.
(4) one of these must be deleted unless both apply.
BLANK FOR ADMIN PURPOSES - DO NOT REMOVE
Scottish Statutory Instrument 2001 No 79
Adults with Incapacity (Scotland) Act 2000 ("the Act")
Evidence to inform decision to dispense with notification 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 the 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 the authority to intromit with funds.
the reason for this opinion is
(Signed) (Date)
* the person signing the certificate must be a medical practitioner; insert as appropriate, e.g. GP, specialist in
mental disorder
NOTES (FOR COMPLETION OF SSI 79)
Under section 11(2) of the Act, we may dispense with intimation or notification to an adult under
the Act, if it is considered that this would be likely pose a serious risk to their health. Under
section 7(1)(d) of the Act, the Scottish Ministers prescribe the evidence which we shall take into
account when deciding under section 11(2) whether to dispense with intimation or notification.
This certificate (SSI 79) should be used to provide such evidence when it is necessary. It
should be attached to the certificate of capacity (SSI 51) and accompany an application made
under section 26 of the Act for authority to intromit with funds.
The Adults with Incapacity (Evidence in Relation to Dispensing with Intimation or
Notification) (Scotland) Regulations 2001 prescribe that intimation or notification may be
dispensed with on production of certificates from two medical practitioners that such intimation
or notification would pose a serious risk to their health. The regulations also prescribe that:
zThe two medical practitioners must be independent of each other
zIn any case where the incapacity of the adult is by reason of mental disorder, one of the
two medical practitioners must be a medical practitioner approved for the purposes of
Section 22 of the Mental Health (Care and Treatment)(Scotland) Act 2003 as having
special experience in the diagnosis or treatment of mental disorder.
BOTH SECTIONS OF THIS CERTIFICATE (SSI 79) MUST BE COMPLETED AND THE TWO
DOCTORS SIGNING MUST FULFIL THE REQUIREMENTS ABOVE.
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome