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Mental Capacity Act 2005
DEPRIVATION OF LIBERTY FORM No. 26
NOTICE OF THE PENDING TERMINATION OF YOUR APPOINTMENT
AS A REPRESENTATIVE
The representative’s appointment expires when the standard authorisation comes to an end. The selection
and appointment process must be done afresh if a further standard authorisation is required because
the existing one is coming to an end. The same representative may be appointed again where
appropriate.
The representative’s appointment may also be terminated in certain other circumstances as speci ed in Part
B of this form.
PART A — BASIC INFORMATION
Name and address of representative previously
appointed for the person
Full name of the person being deprived of
their liberty
Their date of birth (or estimated age if
unknown)
Name and address of the relevant hospital
or care home
Name and address of the supervisory body
Person to contact at the supervisory body
Name
Address
Name
DOB d d m m y y y y
Est. age
Name
Address
Name
Address
Name
Telephone
Email
CASE
NUMBER
GFSB-Liberty Form 26.indd 1 19/2/09 13:27:47
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PART B — PENDING TERMINATION OF YOUR APPOINTMENT
Your appointment as the person’s representative is to terminate on the date shown below because:
Place a cross in the relevant box below (B1–B6) Ø
B1 The standard authorisation will expire on that date.
B2 The person selected you to be their representative and they have informed the
supervisory body that they now object to you continuing to be their representative.
B3 A donee of a lasting power of attorney or deputy appointed by the Court of Protection who
selected you has now informed the supervisory body that they now object to you
continuing to be the person’s representative.
B4 The supervisory body is satis ed that you are not maintaining suf cient contact with
the person in order to support and represent them.
B5 The supervisory body is satis ed that you are not acting in the best interests
of the person.
B6 The supervisory body is satis ed that you are no longer eligible, or were not eligible
at the time of appointment, to be a representative.
PART C — DATE ON WHICH YOUR APPOINTMENT TERMINATES
Your appointment will terminate at the end of the day on:
Enter date above ×
If you wish to make any representations as to why your appointment should not terminate on this date then
please make them to the supervisory body before then.
PART D — THE SUPERVISORY BODY’S REASONS
If your appointment is to be terminated on ground B4, B5 or B6 above, the supervisory body’s reasons for
deciding that the particular ground applies are as follows:
Signed
(on behalf of the supervisory body)
Dated
ddm
m
yyyy
Signature
Print name
Position
Date
GFSB-Liberty Form 26.indd 2 19/2/09 13:27:48
Please Use Continuation Sheet
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signature
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