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Appointment of Enduring GuardianFor New South Wales
(Guardianship Regulation 2016, Schedule 1)
Important information to read before completing the Enduring Guardianship appointment form• AnEnduringGuardianshipappointmentisanimportantdocument.Itallows
someoneelsetomakemedicalandlifestyledecisionsonyourbehalf.Youshouldgetlegalormedicaladvice(orboth)beforeyousignit.
• ItisimportantthatyoutrustthepersonyouappointasyourEnduringGuardiantomakeappropriatelifestyledecisionsonyourbehalf.Itisrecommendedyouinformthispersonofyourwishesaboutlifestyledecisionsandinvolvethemindiscussionsaboutyourviewsorgoals.Ifthesechange,itisimportanttoletyourEnduringGuardianknow.
• AnEnduringGuardiancanonlymakelifestyledecisionssuchashealthdecisions.You shouldmakeanEnduringPowerofAttorneyifyouwantsomeonetomakefinancialdecisionsonyourbehalfifyoulosecapacity.
• IfyouappointmorethanoneEnduringGuardian,youshouldindicatewhethertheEnduringGuardiansaretoactjointly,severallyorjointlyandseverally.EnduringGuardianswhoareappointedjointlyareonlyabletomakedecisionsiftheyallagreeaboutthedecision.EnduringGuardianswhoareappointedseverallyorjointlyandseverallyareabletomakedecisionsindependentlyofeachother.
• IfyouappointasubstituteEnduringGuardian*,theywillonlyhaveauthoritytoactasyourguardianifthefirstappointedenduringguardian/sdies,resignsorbecomesincapacitated.
• EachEnduringGuardianmustsigntheiracceptanceontheappointmentforittobeeffective.
• Ifsomeonesignstheappointmentonyourbehalf,theymustbeatleast18yearsold.TheymustnotbethepersonbeingappointedasanEnduringGuardian.They cannotalsowitnesstheexecutionoftheappointment.
• IfyoumarryafteryouappointanEnduringGuardianthentheappointmentwillautomaticallyberevoked(unlessyoumarriedyourEnduringGuardian).
• YourEnduringGuardiancanresignatanytime,bygivingyounoticeinwriting.If youhavelostcapacitytomakedecisionsatthattimethenyourEnduringGuardiancanonlyresignwiththeapprovaloftheNSWCivil&AdministrativeTribunal.
• EnduringGuardianshipappointmentsarenotautomaticallyaccessibleonanypublicregister.Therefore,itisimportantthatkeypeopleareawareoftheappointmentsotheycancontacttheEnduringGuardianifrequired.YoushouldprovideacopyoftheEnduringGuardianshipappointmenttoyourEnduringGuardianandkeepacopyinasafeplace.Youshouldalsoletclosefriendsorfamilyknowaboutitandgiveacopytoyoursolicitor,doctorandhealthservice provider.
• Furtherinformation: TheOfficeofthePublicGuardiancanprovideinformationonguardianship, call 02 8688 6070.
NSWTrustee&GuardiancanprepareandwitnessyourEnduringGuardianship,call 1300 364 103.
NSWCivil&AdministrativeTribunalGuardianshipDivisionshouldbecontactedifapersondoesnothavelegalcapacityorthereareconcernsaboutwhethersomeonehadcapacitywhenanEnduringGuardianshiporPowerofAttorney wasprepared,call1300 006 228.
*previouslyreferredtoasalternateguardian
EnduringGuardianshipAppointmentFormNewSouthWales Page1of11
Appointment of Enduring GuardianFor New South Wales
(Guardianship Regulation 2016, Schedule 1)
1. Appointment of Enduring Guardian/s
I, [your full name]: __________________________________________________
Of [your address]: __________________________________________________
__________________________________________________________________
Occupation: _______________________________________________________
Phonenumber: ____________________________________________________
Dateofbirth: ______________________________________________________
Appoint [guardian’s name]: __________________________________________
Of[guardian’s address]: _____________________________________________
__________________________________________________________________
Phone number: ____________________________________________________
Occupation: _______________________________________________________
Appoint [guardian’s name]: __________________________________________
Of[guardian’s address]: _____________________________________________
__________________________________________________________________
Phonenumber: ____________________________________________________
Occupation: _______________________________________________________
Appoint [guardian’s name]: __________________________________________
Of[guardian’s address]: _____________________________________________
__________________________________________________________________
Phonenumber: ____________________________________________________
Occupation: _______________________________________________________
to be my Enduring Guardian/s.
2. Optional – substitute guardian
I appoint [substitute Enduring Guardian’s name]: ________________________
__________________________________________________________________
Of[address]: _______________________________________________________
__________________________________________________________________
Phonenumber: ____________________________________________________
Occupation: _______________________________________________________
to be my substitute Enduring Guardian.
Completeyourdetails inthespaceprovided.
Appointor – ThepersonwhomakesanEnduringGuardianappointmentisknownas theappointor.
Enduring Guardians – YoumayappointoneormorepeopletobeyourEnduringGuardian/s.
IfyouareappointingmorethanoneEnduringGuardiancompletedetailsforeachguardian.
Note:anEnduringGuardianmustbe18 yearsofageandnot haveanyconnectionwith thosewhoprovideyouwithaccommodation,healthcareorservicesforafee.
Completethissectionif youwishtoappointa substituteguardian.
AsubstituteguardianissomeoneyouappointtobeyourEnduringGuardianifyour EnduringGuardian/sdies,resignsorbecomesincapacitated.
Note:Crossoutthissectionifyoudonotwish toappointasubstituteguardian.
EnduringGuardianshipAppointmentFormNewSouthWales Page2of11
3. How I wish my Enduring Guardians to act
[Complete only if more than one Enduring Guardian has been appointed]
TicktheapplicableboxbelowtoindicatewhetheryouareappointingyourEnduring Guardianstoactjointly,severallyorjointlyandseverally.
Alsoindicatebytickingtheappropriateboxwhetheryouwantyourjointly/jointlyandseverallyappointedEnduringGuardian/stocontinueintheirrolein theeventof death,resignationorlossofcapacity.
3a) Joint appointment
IappointmyEnduringGuardianstoactjointlyand [tick applicable box below]
IwanttheappointmenttobeterminatedifoneofmyEnduringGuardians dies,resignsorlosescapacity.
OR
IdonotwanttheappointmenttobeterminatedifoneofmyEnduring Guardiansdies,resignsorlosescapacity.
3b) Several appointment
IappointmyEnduringGuardianstoactseverally.
3c) Joint and several appointment
IappointmyEnduringGuardianstoactjointlyandseverallyand [tick applicable box below]
Iwanttheappointmenttobeterminatedifoneofmy EnduringGuardiansdies,resignsorlosescapacity.
OR
Idonotwanttheappointmenttobeterminatedifoneof myEnduringGuardiansdies,resignsorlosescapacity.
Tickapplicablebox/estoindicatehowyouwishyourEnduringGuardianstomakedecisionsonyourbehalf.
Jointly ThismeanstheEnduringGuardiansmustagreeandmakealldecisionstogether.
IfyouhaveappointedyourEnduringGuardianstoactjointlyyourEnduringGuardianshipappointmentwillautomaticallyterminateifoneofyourEnduringGuardians dies, resigns or becomesincapacitated.IfyoudonotwanttheappointmenttoterminatebutwanttheremainingEnduringGuardian/stocontinue in their role then ticktheappropriatebox.
Severally ThismeanstheEnduringGuardianscanmakedecisionsseparatelyof eachother.
IfyouhaveappointedyourEnduringGuardianstoactseverallyyourEnduringGuardianshipappointmentwillautomaticallycontinueifoneofyourEnduringGuardians dies, resigns or becomesincapacitated.
Jointly and severally ThismeanstheEnduringGuardianscaneithermakedecisions together or separately.
Ifyouhaveappointed yourEnduringGuardianstoactjointlyandseverallyyourEnduringGuardianshipappointmentwillautomaticallycontinueifoneofyourEnduringGuardians dies, resigns or becomesincapacitated.Ifyoudonotwanttheappointmenttocontinuebutwantittoterminatethentickthe appropriatebox.
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4. Functions and limits of my Enduring Guardian/s
ShouldIbecomeincapableofmakingmyownpersonaldecisionsI authorisemyEnduringGuardian/stoexercisethefollowingfunctions:[tick any one or more boxes below]
todecidewhereIlive
LimitsonauthorityofEnduringGuardian: ______________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
todecidewhathealthcareIreceive
LimitsonauthorityofEnduringGuardian: ______________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
todecidewhatotherkindsofpersonalservicesIreceive
LimitsonauthorityofEnduringGuardian: ______________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
toconsenttothecarryingoutofmedicalordentaltreatmentonme (in accordance with Part 5 of the Guardianship Act 1987)
LimitsonauthorityofEnduringGuardian: ______________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
todecide:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
EnduringGuardian/scanonlymakehealthandlifestyledecisions.YoushouldmakeanEnduringPowerofAttorneyifyouwantsomeonetomakefinancialdecisionsonyourbehalf.
SelectwhatfunctionsyouwishyourEnduringGuardian/stohaveshouldyoulosecapacitytomakedecisionsyourself.
Youmayplacelimitson thesefunctions.If you wishtoplacealimit onthefunctionprovidedetailsinthespacebeloweachfunction.
Note: YourEnduringGuardian/scanonlyexercisethesefunctionsifyouhavelostthecapacitytomakedecisionsyourself.
YoumayaddanyadditionalfunctionsyouwishyourEnduringGuardian/stoexerciseon yourbehalf.
Forexampleotherfunctionscouldinclude:
• access(makingdecisionsaboutwho youshouldhave contactwith).
• restrictivepractices(decidingwhethertoconsenttotheuseofphysicalrestraintforalimitedperiodtoprotectyoufromselfharm).
EnduringGuardianshipAppointmentFormNewSouthWales Page4of11
5. Optional – directions to my Enduring Guardian/s
ThefunctionsofmyEnduringGuardian/smustbeexercisedinaccordancewiththefollowingdirections:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
YoumaygiveyourEnduringGuardian/sdirectionsabouthowyou wantthemtocarryouttheirfunctions.
Forexample,youcandirectthemtoconsultotherfamilymembersbeforemakingadecisionorgivedetailsaboutthekindofplaceyouwouldliketoliveifyoulostcapacity.
Note:AnEnduringGuardianmustexercisetheirfunctionsaccordingtoanydirectionsyougivethem.
Youcanonlygivelawfuldirections.YoucannotgivedirectionstoyourEnduringGuardian/stodosomethingwhichisagainstthelaw.
YoumaywishtodirectyourEnduringGuardiantorefertoyourAdvanceCareDirectivewhenmakingmedicalandhealthcaredecisions.
EnduringGuardianshipAppointmentFormNewSouthWales Page5of11
6. Appointor’s signature and witness certificate
(Option – for Enduring Guardian signature/witness)
6a) My signature
Signature ___________________________ Date ________________________
6b) Optional – signature on my behalf
Theappointorinstructedmetosignthisappointmentontheirbehalf.
Signatureonbehalfofappointor _____________________________________
Date _____________________________________________________________
Signer’sfullname __________________________________________________
Signer’s address ___________________________________________________
Signer’sphonenumber: ____________________________________________
6c) Acceptance by Enduring Guardian
[Complete only if witnessed at the same time and by the same witness as appointor. Cross out if this does not apply]
IacceptmyappointmentasEnduringGuardian.
Fullname _________________________________________________________
Signature ___________________________ Date ________________________
6d) My witness certificate
I, [your full name]: __________________________________________________
Of[your address]: __________________________________________________
Phonenumber: ____________________________________________________
Occupation: Australianlegalpractitioner
RegistraroftheNSWLocalCourt
Overseas-registeredforeignlawyer
ApprovedemployeeofNSWTrustee&Guardian
Certify that [Tick applicable boxes below, cross out those which do not apply]
Theappointorappearedtounderstandtheeffectofthisinstrumentand voluntarilyexecutedtheinstrumentinmypresence.
Theappointorvoluntarilyinstructed[insert signer’s full name]
_____________________________________________________________ tosigntheinstrumentontheirbehalfandthatpersonexecutedthe
instrumentinmypresence.
_____________________________________________________________
[insert name of person accepting appointment as Enduring Guardian]appearedtounderstandtheeffectofthisinstrumentandvoluntarilyexecutedtheinstrumentinmypresence.
Signature ___________________________ Date ________________________
You and your Enduring Guardian can sign this page at the same time, in front of the same witness.
If your Enduring Guardian’s signature is witnessed at a different time or by a different witness, they will need a separate witness certificate. Complete additional signature and witness certificate pages.
Note: Beforeyousignhereyoumustarrangeforawitnesstowatchyousignthisappointmentandcertifythatyouappear to understand this appointment.Yourwitnessneedstocompletetheirdetailsin section6d)below.
Ifyouarephysicallyunabletosignaskthepersonsigningforyouto signandcompletetheirdetailsopposite.Thepersonmustbeover18yearsandmustnotbethepersonbeingappointedorthewitnessasdescribedbelow.
ThewitnesscannotbetheEnduringGuardian,or asubstituteEnduringGuardian.
Thewitnessmustbe anAustralianlegalpractitioner/Registrarof theNSWLocalCourt/overseas-registeredforeignlawyerorapprovedemployeeofNSWTrustee&Guardian.Only thesepersonscanwitnesstheexecutionofthisappointment.
EachEnduringGuardianmustsigntheiracceptanceontheappointmentforittobeeffective.
IMPORTANT Refer to checklist before completing this section
EnduringGuardianshipAppointmentFormNewSouthWales Page6of11
7. Optional – substitute Enduring Guardian’s acceptance and witness certificate
7a) Acceptance by substitute Enduring Guardian
[Complete only if substitute Enduring Guardian appointed]
IacceptmyappointmentasEnduringGuardian.
Fullname _________________________________________________________
Signature ___________________________ Date ________________________
7b) Substitute Enduring Guardian’s witness certificate
I, [full name]: _______________________________________________________
Of[address]: _______________________________________________________
__________________________________________________________________
Phonenumber: ____________________________________________________
Occupation: Australianlegalpractitioner
RegistraroftheNSWLocalCourt
Overseas-registeredforeignlawyer
ApprovedemployeeofNSWTrustee&Guardian
Certify that _______________________________________________________
[insert name of person accepting appointment as substitute Enduring Guardian]appearedtounderstandtheeffectofthisinstrumentandvoluntarilyexecutedtheinstrumentinmypresence.
Signature ___________________________ Date ________________________
Note: BeforethesubstituteEnduringGuardiansignsheretheymustarrangeforawitnesstowatchthemsignthisform.Thewitnessneedstocompletetheirdetailsin section7b)below.
ThewitnesscannotbetheEnduringGuardian,or asubstituteEnduringGuardian/s.
Thewitnessmustbe anAustralianlegalpractitioner/Registrarof theNSWLocalCourt/overseas-registeredforeignlawyerorapprovedemployeeofNSWTrustee&Guardian.Onlythesepersonscanwitnesstheexecutionofthisappointment.
EnduringGuardianshipAppointmentFormNewSouthWales Page7of11
8. Enduring Guardian’s acceptance and witness certificate
8a) Acceptance by Enduring Guardian
[Cross out if Enduring Guardian has already signed and Enduring Guardian’s witness certificate has been completed]
IacceptmyappointmentasEnduringGuardian.
Fullname _________________________________________________________
Signature ___________________________ Date ________________________
8b) Enduring Guardian’s witness certificate
I, [full name]: ________________________________________________________
Of[address]: ________________________________________________________
___________________________________________________________________
Phonenumber: _____________________________________________________
Occupation: Australianlegalpractitioner
RegistraroftheNSWLocalCourt
Overseas-registeredforeignlawyer
ApprovedemployeeofNSWTrustee&Guardian
Certify that _______________________________________________________
[insert name of person accepting appointment as Enduring Guardian]appearedtounderstandtheeffectofthisinstrumentandvoluntarilyexecutedtheinstrumentinmypresence.
Signature ___________________________ Date ________________________
Note: BeforetheEnduringGuardiansignsheretheymustarrangeforawitnesstowatchthemsignthisform.Thewitnessneedstocompletetheirdetailsin section8b)below.
ThewitnesscannotbetheEnduringGuardian,or asubstituteEnduringGuardian/s.
Thewitnessmustbe anAustralianlegalpractitioner/RegistraroftheNSWLocalCourt/overseas-registeredforeignlawyerorapprovedemployeeofNSWTrustee&Guardian.Onlythesepersonscanwitnesstheexecutionofthisappointment.
YourEnduringGuardian/scanresignatanytimebygivingyounoticeinwriting.Ifyouhavelostcapacityatthattime,thenyourEnduringGuardian/scanonlyresignwiththeapprovaloftheNSWCivil&AdministrativeTribunal.
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9. Additional Enduring Guardian’s signature and witness certificate/s
[Cross out if Enduring Guardian has already signed and Enduring Guardian’s witness certificate has been completed]
9a) Acceptance by Enduring Guardian
IacceptmyappointmentasEnduringGuardian.
Fullname _________________________________________________________
Signature ___________________________ Date ________________________
9b) Enduring Guardian’s witness certificate
[Cross out if Enduring Guardian’s signature already witnessed]
I, [full name]: _______________________________________________________
Of [address]: _______________________________________________________
__________________________________________________________________
Phonenumber: ____________________________________________________
Occupation: Australianlegalpractitioner
RegistraroftheNSWLocalCourt
Overseas-registeredforeignlawyer
ApprovedemployeeofNSWTrustee&Guardian
Certify that _______________________________________________________
[insert name of person accepting appointment as Enduring Guardian]appearedtounderstandtheeffectofthisinstrumentandvoluntarilyexecutedtheinstrumentinmypresence.
Signature ___________________________ Date ________________________
Note: Beforeyousignhereyoumustarrangeforawitnesstowatchyousignthisform.Thewitnessneedstocompletetheirdetailsinsection9b)below.
Thewitnessescannotbe theEnduringGuardian,orasubstituteEnduringGuardian/s.
Thewitnessmustbe anAustralianlegalpractitioner/RegistraroftheNSWLocalCourt/overseas-registeredforeignlawyerorapprovedemployeeofNSWTrustee&Guardian.Onlythesepersonscanwitnesstheexecutionofthisappointment.
EnduringGuardianshipAppointmentFormNewSouthWales Page9of11
9aa) Acceptance by Enduring Guardian
[Cross out if Enduring Guardian has already signed and Enduring Guardian’s witness certificate has been completed]
IacceptmyappointmentasEnduringGuardian.
Fullname _________________________________________________________
Signature ___________________________ Date ________________________
9bb) Additional Enduring Guardian’s witness certificate
[Cross out if Enduring Guardian’s signature already witnessed]
I, [full name]: _______________________________________________________
Of[address]: _______________________________________________________
__________________________________________________________________
Phonenumber: ____________________________________________________
Occupation: Australianlegalpractitioner
RegistraroftheNSWLocalCourt
Overseas-registeredforeignlawyer
ApprovedemployeeofNSWTrustee&Guardian
Certify that _______________________________________________________
[insert name of person accepting appointment as Enduring Guardian]appearedtounderstandtheeffectofthisinstrumentandvoluntarilyexecutedtheinstrumentinmypresence.
Signature ___________________________ Date ________________________
Note: Beforeyousignhereyoumustarrangeforawitnesstowatchyousignthisform.Thewitnessneedstocompletetheirdetailsinsection9bb)below.
Thewitnessescannotbe theEnduringGuardian,orasubstituteEnduringGuardian/s.
ThewitnessmustbeanAustralianlegalpractitioner/RegistraroftheNSWLocalCourt/overseas-registeredforeignlawyerorapprovedemployeeofNSWTrustee&Guardian.Onlythesepersonscanwitnesstheexecutionofthisappointment.
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Enduring Guardianship Checklist
CheCklistPlease read below and tick to ensure you have completed all details of your Enduring Guardianship appointment correctly.
1. IhavespokentomyproposedEnduringGuardian/sanddiscussedthisappointmentwiththemtoensuretheyarewillingandabletotakeonthisroleandexercisethefunctionsIwishtogivethemasdescribedin sections3and4.
2. ItrustmyEnduringGuardian/sandhavespokentothemaboutthekindoflifestyledecisionsIwishthemtomakeonmybehalfshouldIlosecapacity.If thesechange,IunderstanditisimportanttoletmyEnduringGuardian/sknow.
3. IhavediscussedtheappointmentofmyEnduringGuardian/swithmyclosefriends/familytoletthemknowofmydecisiontoappointanEnduringGuardian.
4. Ihaveconsideredtheoptioninsection2ofappointingasubstituteguardianshouldmyfirstappointedEnduringGuardiandie,resignorbecomeincapacitated.
5. IhaveindicatedhowIwishmyEnduringGuardianstoact(i.e.jointly,severallyorjointlyandseverally)bycompletingsection3.
6. IunderstandIcanasksomeonetosignthisappointmentonmybehalfinsection6ifIamphysicallyunabletosign.Thispersonmustbeovertheageof18andcannotbemyEnduringGuardian/sorawitnesstothisappointment.
7. Iunderstandthecertificateofwitnessneedstobecompletedbyaneligiblewitness,i.e.anAustralianlegalpractitioner/RegistraroftheNSWLocalCourt/overseas-registeredforeignlawyerorapprovedemployeeofNSWTrustee &Guardian.
8. IunderstandmyEnduringGuardian/sneedtosigntheiracceptanceoftheEnduringGuardianappointmentbeforeitcanoperate.
9. IunderstanditisimportanttogiveacopyofthisEnduringGuardianshipappointmenttomyEnduringGuardian/sandotherrelevantpeople,suchasmyGPandattorney,andIwillkeepacopyinasafeplace.ThereisnopublicregisterforEnduringGuardianshipappointments.
10.IunderstandthatifImarry,theEnduringGuardianshipappointmentwillberevokedunlessIammarryingmyEnduringGuardian.
11.Iunderstanditisadvisabletogetmedicalandlegaladvicebeforesigningmy EnduringGuardianshipappointment.
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