Enduring Guardianship in New South Wales...[insert name of person accepting appointment as Enduring Guardian] appeared to understand the effect of this instrument and voluntarily executed

Enduring Guardianshipin New South WalesAPPOINTMENT OF ENDURING GUARDIAN FORM

Revised November 2019

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.Youshould getlegalormedicaladvice(orboth)beforeyousignit.

• ItisimportantthatyoutrustthepersonyouappointasyourEnduringGuardian tomakeappropriatelifestyledecisionsonyourbehalf.Itisrecommendedyou informthispersonofyourwishesaboutlifestyledecisionsandinvolvethemin discussionsaboutyourviewsorgoals.Ifthesechange,itisimportanttoletyour EnduringGuardianknow.

• AnEnduringGuardiancanonlymakelifestyledecisionssuchashealthdecisions. You shouldmakeanEnduringPowerofAttorneyifyouwantsomeonetomake financialdecisionsonyourbehalfifyoulosecapacity.

• IfyouappointmorethanoneEnduringGuardian,youshouldindicatewhetherthe EnduringGuardiansaretoactjointly,severallyorjointlyandseverally.Enduring Guardianswhoareappointedjointlyareonlyabletomakedecisionsiftheyall agreeaboutthedecision.EnduringGuardianswhoareappointedseverallyor jointlyandseverallyareabletomakedecisionsindependentlyofeachother.

• IfyouappointasubstituteEnduringGuardian*,theywillonlyhaveauthorityto actasyourguardianifthefirstappointedenduringguardian/sdies,resignsor becomesincapacitated.

• EachEnduringGuardianmustsigntheiracceptanceontheappointmentforitto beeffective.

• Ifsomeonesignstheappointmentonyourbehalf,theymustbeatleast18years old.TheymustnotbethepersonbeingappointedasanEnduringGuardian. They cannotalsowitnesstheexecutionoftheappointment.

• IfyoumarryafteryouappointanEnduringGuardianthentheappointmentwill automaticallyberevoked(unlessyoumarriedyourEnduringGuardian).

• YourEnduringGuardiancanresignatanytime,bygivingyounoticeinwriting.If you havelostcapacitytomakedecisionsatthattimethenyourEnduringGuardiancan onlyresignwiththeapprovaloftheNSWCivil&AdministrativeTribunal.

• EnduringGuardianshipappointmentsarenotautomaticallyaccessibleonanypublic register.Therefore,itisimportantthatkeypeopleareawareoftheappointmentso theycancontacttheEnduringGuardianifrequired.Youshouldprovideacopyof theEnduringGuardianshipappointmenttoyourEnduringGuardianandkeepacopy inasafeplace.Youshouldalsoletclosefriendsorfamilyknowaboutitandgivea copytoyoursolicitor,doctorandhealthservice provider.

• Furtherinformation:ThePublicGuardiancanprovideinformationonguardianship, call 02 8688 6070.NSWTrustee&GuardiancanprepareandwitnessyourEnduringGuardianship, call 1300 364 103.NSWCivil&AdministrativeTribunalGuardianshipDivisionshouldbecontactedifapersondoesnothavelegalcapacityorthereareconcernsaboutwhether someonehadcapacitywhenanEnduringGuardianshiporPowerofAttorney 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: _______________________________________________________



__________________________________________________________________

Phonenumber: ____________________________________________________

Occupation: _______________________________________________________



__________________________________________________________________

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.


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]

IwanttheappointmenttobeterminatedifoneofmyEnduringGuardiansdies,resignsorlosescapacity.

OR

IdonotwanttheappointmenttobeterminatedifoneofmyEnduringGuardiansdies,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.


4. Functions and limits of my Enduring Guardian/s

ShouldIbecomeincapableofmakingmyownpersonaldecisionsI authorisemyEnduringGuardian/stoexercisethefollowingfunctions:[tick any one or more boxes below]

todecidewhereIlive

LimitsonauthorityofEnduringGuardian: ______________________________

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todecidewhathealthcareIreceive


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todecidewhatotherkindsofpersonalservicesIreceive


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toconsenttothecarryingoutofmedicalordentaltreatmentonme(in accordance with Part 5 of the Guardianship Act 1987)


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todecide:

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EnduringGuardian/scanonlymakehealthandlifestyledecisions.YoushouldmakeanEnduringPowerofAttorneyifyouwantsomeonetomakefinancialdecisionsonyourbehalf.

SelectwhatfunctionsyouwishyourEnduringGuardian/stohaveshouldyoulosecapacitytomakedecisionsyourself.

Youmayplacelimitson thesefunctions.If you wishtoplacealimit onthefunctionprovidedetailsinthespacebeloweachfunction.

Note: YourEnduringGuardian/scanonlyexercisethesefunctionsifyouhavelostthecapacitytomakedecisionsyourself.

YoumayaddanyadditionalfunctionsyouwishyourEnduringGuardian/stoexerciseon yourbehalf.

Forexampleotherfunctionscouldinclude:

• access(makingdecisions aboutwho youshould have contactwith).

• restrictivepractices(decidingwhetherto consenttotheuseof physicaland/or chemical restraintfora limited periodtoprotect youfrom selfharm).


5. Optional – directions to my Enduring Guardian/s

ThefunctionsofmyEnduringGuardian/smustbeexercisedinaccordancewiththefollowingdirections:

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YoumaygiveyourEnduringGuardian/sdirectionsabouthowyou wantthemtocarryouttheirfunctions.

Forexample,youcandirectthemtoconsultotherfamilymembersbeforemakingadecisionorgivedetailsaboutthekindofplaceyouwouldliketoliveifyoulostcapacity.

Note:AnEnduringGuardianmustexercisetheirfunctionsaccordingtoanydirectionsyougivethem.

Youcanonlygivelawfuldirections.YoucannotgivedirectionstoyourEnduringGuardian/stodosomethingwhichisagainstthelaw.

YoumaywishtodirectyourEnduringGuardiantorefertoyourAdvanceCareDirectivewhenmakingmedicalandhealthcaredecisions.


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]

_____________________________________________________________tosigntheinstrumentontheirbehalfandthatpersonexecutedtheinstrumentinmypresence.

_____________________________________________________________

[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


7. Optional – substitute Enduring Guardian’sacceptance and witness certificate

7a) Acceptance by substitute Enduring Guardian

[Complete only if substitute Enduring Guardian appointed]


Fullname _________________________________________________________

Signature ___________________________ Date ________________________

7b) Substitute Enduring Guardian’s witness certificate

I, [full name]: _______________________________________________________

Of[address]: _______________________________________________________

__________________________________________________________________

Phonenumber: ____________________________________________________





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.


8. Enduring Guardian’s acceptance and witnesscertificate

8a) Acceptance by Enduring Guardian

[Cross out if Enduring Guardian has already signed and Enduring Guardian’s witness certificate has been completed]


Fullname _________________________________________________________

Signature ___________________________ Date ________________________

8b) Enduring Guardian’s witness certificate

I, [full name]: ________________________________________________________

Of[address]: ________________________________________________________

___________________________________________________________________

Phonenumber: _____________________________________________________





Certify that _______________________________________________________


Signature ___________________________ Date ________________________

Note: BeforetheEnduringGuardiansignsheretheymustarrangeforawitnesstowatchthemsignthisform.Thewitnessneedstocompletetheirdetailsin section8b)below.

ThewitnesscannotbetheEnduringGuardian,or asubstituteEnduringGuardian/s.

Thewitnessmustbe anAustralianlegalpractitioner/RegistraroftheNSWLocalCourt/overseas-registeredforeignlawyerorapprovedemployeeofNSWTrustee&Guardian.Onlythesepersonscanwitnesstheexecutionofthisappointment.

YourEnduringGuardian/scanresignatanytimebygivingyounoticeinwriting.Ifyouhavelostcapacityatthattime,thenyourEnduringGuardian/scanonlyresignwiththeapprovaloftheNSWCivil&AdministrativeTribunal.


9. Additional Enduring Guardian’s signature and witness certificate/s


9a) Acceptance by Enduring Guardian


Fullname _________________________________________________________

Signature ___________________________ Date ________________________

9b) Enduring Guardian’s witness certificate

[Cross out if Enduring Guardian’s signature already witnessed]

I, [full name]: _______________________________________________________

Of [address]: _______________________________________________________

__________________________________________________________________

Phonenumber: ____________________________________________________





Certify that _______________________________________________________


Signature ___________________________ Date ________________________

Note: Beforeyousignhereyoumustarrangeforawitnesstowatchyousignthisform.Thewitnessneedstocompletetheirdetailsinsection9b)below.

Thewitnessescannotbe theEnduringGuardian,orasubstituteEnduringGuardian/s.

Thewitnessmustbe anAustralianlegalpractitioner/RegistraroftheNSWLocalCourt/overseas-registeredforeignlawyerorapprovedemployeeofNSWTrustee&Guardian.Onlythesepersonscanwitnesstheexecutionofthisappointment.


9aa) Acceptance by Enduring Guardian



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: ____________________________________________________





Certify that _______________________________________________________


Signature ___________________________ Date ________________________

Note: Beforeyousignhereyoumustarrangeforawitnesstowatchyousignthisform.Thewitnessneedstocompletetheirdetailsinsection9bb)below.

Thewitnessescannotbe theEnduringGuardian,orasubstituteEnduringGuardian/s.

ThewitnessmustbeanAustralianlegalpractitioner/RegistraroftheNSWLocalCourt/overseas-registeredforeignlawyerorapprovedemployeeofNSWTrustee&Guardian.Onlythesepersonscanwitnesstheexecutionofthisappointment.


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.


I your full name: Of your address 1: Occupation: Phone number: Date of birth: Appoint guardians name: Of guardians address 1: Of guardians address 2: Phone number_2: Occupation_2: Appoint guardians name_2: Of guardians address 1_2: Of guardians address 2_2: Phone number_3: Occupation_3: Appoint guardians name_3: Of guardians address 1_3: Of guardians address 2_3: Phone number_4: Occupation_4: I appoint substitute Enduring Guardians name 1: I appoint substitute Enduring Guardians name 2: Of address 1: Of address 2: Phone number_5: Occupation_5: to dec: OffLim 1: to dec_2: OffLim 1_2: to dec_3: OffLim 1_3: to consent to the carrying out of med: OffLim 1_4: to dec_4: Offi 1: w 1: Date: f of appointor: Date_2: name: Signers address: Signers phone number: name_2: Date_3: I your full name_2: Of your address: Phone number_6: Austra: OffRegistrar of the NSW Loca: OffOverseasregistered fore: OffApproved emp: OffThe appointor appeared to understand the effect of this instrument: OffThe appointor voluntar: Offgn the instrument on their beha: undefined: instrument in my presence: Date_4: name_3: Date_5: I full name: Of address 1_2: Of address 2_2: Phone number_7: Austra_2: OffRegistrar of the NSW Loca_2: OffOverseasregistered fore_2: OffApproved emp_2: OffCertify that: Date_6: name_4: Date_7: I full name_2: Of address 1_3: Of address 2_3: Phone number_8: Austra_3: OffRegistrar of the NSW Loca_3: OffOverseasregistered fore_3: OffApproved emp_3: OffCertify that_2: Date_8: name_5: Date_9: I full name_3: Of address 1_4: Of address 2_4: Phone number_9: Austra_4: OffRegistrar of the NSW Loca_4: OffOverseasregistered fore_4: OffApproved emp_4: OffCertify that_3: Date_10: name_6: Date_11: I full name_4: Of address 1_5: Of address 2_5: Phone number_10: Austra_5: OffRegistrar of the NSW Loca_5: OffOverseasregistered fore_5: OffApproved emp_5: OffCertify that_4: Date_12: 1 I have spoken to my proposed Enduring Guard: Off2 I trust my Enduring Guard: Off3 I have discussed the appointment of my Enduring Guard: Off4 I have cons: Off5 I have ind: Off6 I understand I can ask someone to s: Off7 I understand the cert: Off8 I understand my Enduring Guard: Off9 I understand: Off10 I understand that: Off11 I understand: OffOf your address 2: Existing 2: Off3a_: Off3b_: Off

Documents

Enduring Guardianship in New South Wales...[insert name of person accepting appointment as Enduring Guardian] appeared to understand the effect of this instrument and voluntarily executed