Enduring Power of Attorney Application Form

Enduring Power of Attorney Application

Fill out the form carefully and include middle names where applicable.
Name of Donor (Person setting up the EPA)

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Gender
Address

Street Address

Street Address Line 2

CityCounty

Postcode
E-mail
example@example.com
Mobile Number

Area CodePhone Number
Phone Number

Area CodePhone Number
Work Number

Area CodePhone Number

First Attorney

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityCounty

Postcode
Email
example@example.com
Relationship to You
Required
Second Attorney

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityCounty

Postcode
Email
example@example.com
Relationship to You
Required
Who do you want us to inform that you have an Enduring Power of Attorney in Place?

We suggest 3 people should know you have it and where it is kept.
Name

First NameLast Name
Email
example@example.com
Name

First NameLast Name
Email
example@example.com
Name

First NameLast Name
Email
example@example.com
Do you wish for your Attorneys to act either (jointly) or (jointly and severally) in relation to your property and financial affairs? If you do not want the attorney(s) to have general power, you must give details here of what authority you are giving the attorney.
I acknowledge that this Enduring Power of Attorney is made in accordance with my current mental capacity. I understand that should my mental capacity be questioned in the future, this document is intended to remain in effect, provided it is established that I had the requisite capacity at the time of its execution. Please confirm below that you have read, understood, and agreed to the above statement.
Required
IMPORTANT: The information above is intended to give an overview of issues to

be considered in relation to Enduring Powers of Attorney. It is a general guide

only and you are STRONGLY RECOMMENDED to discuss your personal

circumstances with Protect NI who will guide you through the various

decisions and choices to be made. Nothing in this guide should be construed

as the giving of specific advice and it should not be relied on as a basis for any

decision or action. Neither Protect NI nor any of its associated companies

accepts any liability arising from its use.

DISCLAIMER: The information on this application has been prepared by Protect NI, which we hope will be of use to you. Nothing in this application should be construed as the giving of specific advice and it should not be relied on as a basis for any decision or action. Neither Protect NI nor any of its associated companies accepts any liability arising from its use. We aim to ensure that the information is as up to date and accurate as possible, but please be warned that certain areas are subject to change from time to time. Every effort has been made to ensure that the information contained herein is correct.
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