ADULTS WITH INCAPACITY - (SCOTLAND) ACT 2000
Application form
Access to funds ATF (2) (Version 3)
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. If you previously
submitted this with an ATF (1) application and were issued with a certificate of authority you are not
required to complete again for this application.
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 20
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 reserve withdrawer
(Not applicable if joint applicants applying)
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 2 of 20
Section 1.4 - 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 etc.) Post code
If there has been a court order naming the above as nearest relative please tick this box.
Section 1.5 - 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, care manager etc.) Post code
Section 1.6 - Details of any named person, attorney, intervener or guardian
Title House/no
Forename Street
Middle name Locality
Surname City
Organisation County
Tel no Country
E-mail address Post code
Please indicate role
Named person attorney intervener guardian
if more than one role applies please use a separate page
Page 3 of 20
Section 1.7 - 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: Post code
Title House/no
Forename Street
Middle name Locality
Surname City
Tel no County
E-mail address Country
Relationship: Post code
Title House/no
Forename Street
Middle name Locality
Surname City
Tel no County
E-mail address Country
Relationship: Post code
Title House/no
Forename Street
Middle name Locality
Surname City
Tel no County
E-mail address Country
Relationship: Post code
Please use a separate page if necessary
Page 4 of 20
Section 2 - Financial information
Section 2.1 - Department for Work & Pensions (DWP) appointee
Are you or another person in receipt of their DWP pension, benefits or allowances?
Yes No
Date first payment received
If yes, this application should only be used to request funds required in addition to DWP pension,
benefits or allowances, e.g. savings, occupational/private pension or other income.
If there is an existing current type bank/building society account in their sole name which is suitable for
setting up standing orders/direct debits please provide full details below. This account will be referred to
as the current acccount. If this type of account is required please complete section 2.3
Section 2.2 - Details of existing account in sole name
Bank/Building Society
Branch name
No/building
Street
Locality
City
County
Country
Post code
Sort code
Account number
Account holder
Section 2.3 - Details of proposed new account in sole name
Once open, this account will be referred to as the current account
Bank/Building Society
Branch name
No/building
Street
Locality
City
County
Country
Post code
Sort code
Account holder
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Section 2.4 - Second account
Is there a bank account in his/her sole name which you would wish to operate as a second account?
Yes No
If yes, please provide details below.
Bank/Building Society
Branch name
No/building
Street
Locality
City
County
Country
Post code
Sort code
Account number
Account holder
If no, do you wish authority to open a second account in his/her sole name?
Yes No
If yes, please provide details below.
Bank/Building Society
Branch name
No/building
Street
Locality
City
County
Country
Post code
Sort code
Page 6 of 20
Section 2.5 - Transfer of funds on existing accounts
Where there are several accounts in his/her sole name it may be that you need to close or transfer funds
between these.
Please identify the accounts below and give specific details oif what you want to do.
(If you wish to close an account please indicate "full amount").
Transfer from Transfer to Amount £
Bank/Building Society
Sort code
Account number
Account holder
Do you wish to close this account?
Yes No
Transfer from Transfer to Amount £
Bank/Building Society
Sort code
Account number
Account holder
Do you wish to close this account?
Yes No
Transfer from Transfer to Amount £
Bank/Building Society
Sort code
Account number
Account holder
Do you wish to close this account?
Yes No
If there are more sole accounts, please use an additional page
Page 7 of 20
BLANK FOR ADMIN PURPOSES - DO NOT REMOVE
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Section 2.6 - Details of any direct debits/standing orders on the current account which you wish to
continue or set up
Name of company to whom payment is to be made
(e.g. Scottish Power, Aviva)
Monthly amount £
Continue:
Set up:
Section 2.7 - Use of funds
Reason for expenditure Monthly amount £
Care charges
Clothing
Personal allowance
Mortgage
Rent
Council tax
Gas
Electricity
Telephone (including mobile phones and special telephone services)
TV licence
Insurances (building, contents, motor, personal, pets etc.)
Loan repayments
Food and household expenses
Holidays/outings
Transport costs
Club or other subscriptions
Gifts
Other (Please specify)
Total monthly amount £
Page 9 of 20
0
Section 2.8 - One off lump sum
One off payments/lump sums
(please specify)
Reason for expenditure Amount £
Total lump sum £
Account from which the lump sum will be transferred
the existing current account in Section 2.2
Yes No
the existing second account in Section 2.4
Yes No
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0
Section 2.9 - Additional information
Additional information to support your application e.g. background
Page 11 of 20
Section 3 - Undertaking and declaration by applicant(s)/reserve
Undertaking
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 myself or the adult, for example, change of address, death of 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 and intromitting with those funds; and
b) operate any accounts in the sole name of the adult as directed by my certificate of authority.
Declaration
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 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 joint/
reserve
Signature of joint/
reserve
Print name Print name
Date Date
Page 12 of 20
Section 4 - Countersignatory information
This section does not require to be completed when the information has already been supplied in
form ATF(1)
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)
Please note that we may contact the countersignatory in relation to this application
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 13 of 20
Please delete below
a) I have no pecuniary interest in this application.
b) I have a pecuniary interest in this application.
The nature and extent of any pecuniary interest is:
The countersignatory must now answer the question below providing as much relevant information as
possible.
Please comment below on how you feel that the applicant is a fit and proper person with the ability to
carry out the functions of withdrawer
Signature of countersignatory
Print name
Date
THE APPLICATION MUST BE LODGED WITH THIS OFFICE WITHIN 14 DAYS OF THIS DATE.
Page 14 of 20
Checklist for applicant:
Have you completed all relevant sections?
Has evidence been enclosed to support all requests for funds?
Have all applicant(s) and/or reserves 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?
Have you included any additional information to support the application?
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 be 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.
It is advisable to have the application and enclosures weighed at the Post Office to ensure that
the correct postage is applied.
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
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Print Form Reset Form
BLANK FOR ADMIN PURPOSES - DO NOT REMOVE
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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
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 - insert as appropriate
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.
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