Fillable Form EP2PG: Office of the Public Guardian Mental (Cabinet Office)

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Form EP2PG: Office of the Public Guardian Mental (Cabinet Office)

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The Form EP2PG: Office of the Public Guardian Mental (Cabinet Office) form is 7 pages long and contains:

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Please do not write below this line - For Office Use Only
Office of the Public Guardian
Mental Capacity Act 2005
Form EP2PG
Application for Registration of an Enduring
Power of Attorney
If Other, please
specify here:
Last Name:
Forename 1:
Other
Forenames:
Page 1 of 7
Please state the full name and present address of the donor. State the donor’s first name in ‘Forename 1' and the
donor’s other forenames in full in ‘Other Forenames’. Company Name should be completed with the name of the
nursing/care home or hospital where applicable.
Town/City:
County:
Postcode:
Address 3:
Donor Date
of Birth:
If the exact date is unknown
please state the year of birth
Address 2:
Part One - The Donor
Address 1:
Company
Name:
IMPORTANT: Please complete the form in BLOCK CAPITALS using a black ball-point pen. Place a clear cross 'X'
mark inside square option boxes
- do not circle the option.
D M YYYYMD
Produced in association with the
Office of the Public Guardian
© Crown Copyright 2007
Provider details
Ms Miss Other
Mr Mrs
Place a cross against one option
Reset form
Print form
Reset form
Print form
Appointment (Place a cross against one option ):
If ‘Other Relation’ or ‘Other Professional’, specify
relationship:
Page 2 of 7
Part B of the Enduring Power of Attorney states whether the attorney is to act jointly, jointly and severally, or alone.
Other
Relation
No
Relation Solicitor
Civil Partner /
Spouse
Child
Place a cross against one option
Other
Professional
Jointly
Alone
Jointly and Severally
Town/City:
County:
Postcode:
DX No.
(solicitors only):
DX Exchange
(solicitors only):
Attorney
Date of Birth:
DMYYYYMD
Daytime
Tel No.:
(STD Code):
Email
Address:
Occupation:
Relationship to donor:
Part Two - Attorney One
Please state the full name and present address of the attorney. Professionals e,g, Solicitors or Accountants, should
complete the Company Name field.
If Other, please
specify here:
Last Name:
Forename 1:
Other
Forenames:
Address 3:
Address 2:
Address 1:
Ms Miss OtherMr Mrs
Place a cross against one option
Company
Name:
DX Exchange
(solicitors only):
Page 3 of 7
If ‘Other Relation’ or ‘Other Professional’, specify
relationship:
Other
Relation
No
Relation Solicitor
Civil Partner /
Spouse
Child
Place a cross against one option
Other
Professional
Town/City:
County:
Postcode:
DX No.
(solicitors only):
Attorney
Date of Birth:
DMYYYYMD
Daytime
Tel No.:
(STD Code):
Email
Address:
Occupation:
Relationship to donor:
Part Three - Attorney Two
Please state the full name and present address of the attorney. Professionals e.g. Solicitors or Accountants, should
complete the Company Name field.
If Other, please
specify here:
Last Name:
Forename 1:
Other
Forenames:
Address 3:
Address 2:
Address 1:
Ms Miss OtherMr Mrs
Place a cross against one option
Company
Name:
Part Four - Attorney Three
Please state the full name and present address of the attorney. Professionals e,g, Solicitors or Accountants, should
complete the Company Name field.
If Other, please
specify here:
Last Name:
Forename 1:
Ms Miss OtherMr Mrs
Place a cross against one option
Part Four Continued Overleaf
Part Five - The Enduring Power of Attorney
I (We) the attorney(s) apply to register the Enduring Power of Attorney made by the donor under the Enduring
Powers of Attorney Act 1985, the original, or if the original is lost or destroyed, a certified copy of which
accompanies this application.
I (We) have reason to believe that the donor is or is becoming mentally incapable.
Date that the Donor signed the Enduring Power of Attorney.
You can find this in Part B of the Enduring Power of Attorney.
To your knowledge, has the Donor made any other Enduring
Powers of Attorney?:
If ‘Yes’, please give details below including registration date if applicable:
Page 4 of 7
D M YYYYMD
Yes1R
Place a cross against one option
DX Exchange
(solicitors only):
If ‘Other Relation’ or ‘Other Professional’, specify
relationship:
Town/City:
County:
Postcode:
DX No.
(solicitors only):
Attorney
Date of Birth:
DMYYYYMD
Daytime
Tel No.:
(STD Code):
Email
Address:
Occupation:
Relationship to donor:
Other
Forenames:
Address 3:
Address 2:
Address 1:
Company
Name:
Other
Relation
No
Relation Solicitor
Civil Partner /
Spouse
Child
Place a cross against one option
Other
Professional
Part Four - Attorney Three cont'd
If there are additional attorneys, please complete the above details in the ‘Additional Information’ section (at the end
of this form).
Page 5 of 7
Notice must be given personally to the donor. It should be made clear if someone other than the attorney(s) gives the
notice. The date on which the notice was given MUST be completed.
I (We) have given notice of the application to register in the prescribed form (EP1PG) to the donor personally,
Part Six - Notice of Application to Donor
If someone other than the attorney gives notice to the donor please complete the name and address details below. Please also
complete the date above:
Address 1:
Town/City:
County:
Address 2:
Postcode:
Full Name:
on this date:
Part Seven - Notice of Application to Relatives
I (We) have given notice to register in the prescribed form (EP1PG) to the following relatives of the donor:
Please complete details of all relatives entitled to notice.
Please place a cross in the box
if no relatives are entitled to notice:
D M YYYYMD
Address 3:
Date notice given:
DMYYYYMD
Full Name:
Relationship to Donor:
Address:
Date notice given:
DMYYYYMD
Full Name:
Relationship to Donor:
Address:
Date notice given:
DMYYYYMD
Full Name:
Relationship to Donor:
Address:
Date notice given:
D M YYYYMD
Full Name:
Relationship to Donor:
Address:
Date notice given:
D M YYYYMD
Full Name:
Relationship to Donor:
Address:
If there are additional relatives please complete the Relative Name, Relationship, Address and Date details in the
‘Additional Information’ section (at the end of this form).
If no, I (We) have given notice to my (our) co-attorney(s) as follows:
Do not complete this section if it does not apply. If there are additional co-attorneys please complete the Attorney
Name, Relationship, Address and Date details in the ‘Additional Information’ section (at the end of this form).
Part Eight - Notice of Application to Co-Attorney(s)
Are all the attorneys applying to register?
Part Nine - Fees
Guidelines on remission and postponement of fees can be obtained from the Office of the Public Guardian.
Have you enclosed a cheque for the registration fee for this application?
Do you wish to apply for postponement, exemption or remission of
the fee?
If yes, please complete the application for exemption or remission form.
Page 6 of 7
Place a cross against one option
Date notice given:
DMYYYYMD
Full Name:
Relationship to Donor:
Address:
Date notice given:
DMYYYYMD
Full Name:
Relationship to Donor:
Address:
Place a cross against one option
Yes
No
Yes
No
Yes
No
Part Ten - Declaration
Note: The application should be signed by all attorneys who are making the application. This must not pre-date the
date(s) when the notices were given.
I (We) certify that the above information is correct and that to the best of my (our) knowledge and belief I (We) have
complied with the provisions of the Mental Capacity Act 2005.
Signed:
Dated:
D M YYYYMD
Signed: Dated:
D M YYYYMD
Signed: Dated:
D M YYYYMD
Place a cross against one option
Solicitors please note: The address to which the correspondence should be sent MUST be entered here if this is different to
the address of Attorney One. State the full name and present address. Insert the name of the Solicitor's Firm in the Company
Name field, if appropriate, and the correspondence reference in the Company Reference field.
Part Eleven - Correspondence Address
Page 7 of 7
If Other, please
specify here:
Last Name:
Forename 1:
Other
Forenames:
Address 3:
Address 2:
Address 1:
Postcode:
DX No.
(solicitors only):
Town/City:
County:
DX Exchange
(solicitors only):
Daytime
Tel No.:
Email
Address:
(STD Code):
Company
Name:
Company
Reference:
Ms Miss OtherMr Mrs
Place a cross against one option
Part Twelve - Additional Information
Please write down any additional information to support this application in the space below. If necessary attach
additional paper to the end of this form.
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Form EP2PG: Office of the Public Guardian Mental (Cabinet Office)

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Completed 20 July 2021

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