EPA - Personal Care and Welfare Enduring Power of Attorney with respect to Personal Care and Welfare 1 Intro2 Donor3 Attorney(s)4 Successor Attorney(s)5 What your Attorney can act on6 Consultation7 Information8 Additional T&Cs Introduction This online questionnaire is designed to allow you to send us information we need to prepare your Enduring Power of Attorney for Personal Care and Welfare (EPA Personal Care and Welfare). Some quick notes on how people are referred to in this questionnaire. The EPA Personal Care and Welfare gives someone you trust the power to make decisions about your care and welfare if you’re unable to. This person is called your Attorney. The person who gives the power is called the Donor. If you are completing this on behalf of the Donor, please note we also refer to that person as “you”. There are some compulsory questions – these are noted with an asterisk (*). There is guidance and pop up information within the questionnaire to help you along. There are 8 Sections. Each Section has a General or Additional Comments field at the end. This allows you to enter anything you want, and you should feel free to use this if you have any doubts or are unsure about what is being asked in the earlier parts of the Section. If you need to take a break from the questionnaire, you can do so by clicking the Save and Continue Later link at the bottom of each page and you will receive an email with a link to allow you to resume where you left off. Your answers will all be saved automatically. Once you have completed the questionnaire click the SUBMIT button on the last page (Section 8 – Additional Terms and Conditions) and an email will be sent to you and us with your answers. We will follow up with you as required and contact you to organise how the completed EPA Personal Care and Welfare can be “executed” (signed and witnessed by all the relevant people). At any stage you can contact us with questions. If you know the person at Evans Henderson Woodbridge who you want to prepare the EPA Personal Care and Welfare document, or is your usual contact here, then you can select that person in the questionnaire. They will receive a copy of your submitted answers and will follow up with you. If you don’t have a regular contact here then we will be in touch to arrange that for you. Section 1 - Donor Details & Previous EPAs in relation to Personal Care and Welfare In this section and the entire form, we will refer to the person giving the power of attorney as either "Donor" or "you" Name of person giving the enduring power of attorney to act in relation to personal care and welfareFirst Name*Middle Name(s)Surname*Gender*MaleFemaleAddress Street Address Suburb City Post Code Email* Phone (Home and/or mobile)*Date of Birth*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Previous EPAs in relation to my personal care and welfare*This is my first EPA in relation to my personal care and welfareI have one or more previous EPAs in relation to my personal care and welfare which I want to revokeI have one or more previous EPAs in relation to my personal care and welfare which need to be considered alongside this EPAIf you want to maintain any other EPAs in relation to your personal care and welfare please provide details of those EPAs here so we can consider whether there is any overlapping or inconsistencyIf you can, please upload a copy of all and any previous EPAs in relation to your personal care and welfare Drop files here or Do you have a Lawyer or regular contact at Evans Henderson WoodbridgeYesNoSelect ContactJohn HendersonDavid WoodbridgePhil PaytonChris CantillonFrank SherriffJenny PainTeresa CunninghamBonnie BoydPlease advise how you would prefer to be contacted by us after submitting this questionnaire.By PhoneBy EmailYour best contact numberThe best time to contact youMorningLunchtimeAfternoonEveningGeneral or Additional CommentsIf you want to add anything more related to the above questions please do so here. Section 2 - Attorney Details You can appoint only one person to be your Attorney to act on your personal care and welfare matters (although you can appoint successor attorneys).Please confirm that your chosen Attorney is: (all must apply)* not less than 20 years old not bankrupt not mentally incapable First Name*Middle NameSurname*Address Street Address Suburb City Post Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email Contact NumberRelationship to Donor (You)*General or Additional CommentsIf you want to add anything more related to the above questions please do so here. Section 3 - Successor Attorney(s) Details If the appointment of your Attorney appointed in Section 3 ends, then a successor Attorney appointed may act as Attorney in their place.Do you want to appoint a successor Attorney?YesNoUnsureFirst Name*Middle NameSurname*Address Street Address Suburb City Post Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email Contact NumberRelationship to Donor (You)General or Additional CommentsIf you want to add anything more related to the above questions please do so here. Section 4 - What Attorney can act onYour Attorney can act on*All my personal care and welfare mattersOnly the matters relating to my personal care and welfare I have listed belowUnsureList of MattersIs your Attorney's authority to act subject to conditions and restrictions?*YesNoUnsureList of conditions and restrictionsGeneral or Additional CommentsIf you want to add anything more related to the above questions please do so here. Section 5 - Consultation with othersDo you want your Attorney(s) or successor Attorney(s) to consult with anyone else before making decisions?YesNoUnsurePeople to consult with First Name Surname Relationship to Donor/You Actions Edit Delete There are no People to consult with. Add Person to consult with Maximum number of people to consult with reached. General or Additional CommentsIf you want to add anything more related to the above questions please do so here. Section 6 - Providing InformationDo you want to name a person or people who your Attorney(s) need to give information to about how they are carrying out their role?YesNoUnsurePerson Details First Name Surname Relationship to you Information to be given to this person Actions Edit Delete There are no People. Add Person Maximum number of people reached. General or Additional CommentsIf you want to add anything more related to the above questions please do so here. Section 12 - Additional Terms and ConditionsMy EPA is subject to the following additional terms and conditions
