Principal - The person who appoints the attorney is known as the principal.
Attorney - The person you nominate to look after your financial affairs is known
as the attorney. You can appoint more than one attorney.
1. Appointment of attorney by the principal
I, ..............................................................................................................................
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[insert full name and address],
appoint
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and also appoint
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My attorneys are appointed: [Tick one option only]
❏ Jointly [Your attorneys must all act together]. I want the appointment to be
terminated if one of the attorneys dies, resigns or otherwise vacates office.
❏ Jointly [Your attorneys must all act together]. I do not want the appointment to
be terminated if one of the attorneys dies, resigns or otherwise vacates office.
❏ Jointly and severally [Your attorneys may act individually or can act with the
other attorneys if they choose].
If no option is selected or the option chosen is unclear or
inconsistent, I intend my attorneys to act jointly and severally.
Nomination of substitute attorney (optional)
If your attorney vacates office, you have the option to nominate someone
else to take their place.
If my attorney vacates office, I appoint:
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[insert full name and address of substitute attorney/s]
to be my substitute attorney/s.
My substitute attorney/s are to be appointed:
❏ Jointly [Your attorneys must all act together].
Or
❏ Jointly and severally [Your attorneys may act individually or can act with the
other attorneys if they choose]
2. Powers
My attorney may exercise the authority conferred by Part 2 of the
Powers of Attorney Act 2003 to do anything on my behalf I may
lawfully authorise an attorney to do.
I give this power of attorney with the intention that it will continue to
be effective if I lack the capacity through loss of mental capacity after
its execution.
Additional powers (optional)
❏ I authorise my attorney to give reasonable gifts as provided by section 11(2) of
the Powers of Attorney Act 2003.
❏ I authorise my attorney to confer benefits on the attorney to meet their
reasonable living and medical expenses as provided by section 12(2) of the
Powers of Attorney Act 2003.
❏ I authorise my attorney to confer benefits on the following persons to meet
their reasonable living and medical expenses as provided by section 13(2) of
the Powers of Attorney Act 2003. [insert full name and address of each person
below]
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and (delete if not required)
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3. Conditions and Limitations
I place the following conditions and/or limitations on the authority of
my attorney:
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4. Commencement
This power of attorney operates: [Tick one option
only]
❏ Once the attorney has accepted their appointment by signing this document.
❏ Once a medical practioner considers that I am unable to manage my affairs
(an provides a document to that effect).
❏ Once my attorney considers that I need assistance managing my affairs.
❏ Other ................................................................................................................
If no option is selected or the options chosen are unclear or
inconsistent, I intend that the power of attorney will operate once my
attorney has accepted their appointment by signing this document.
5. Your signature to make the appointment
Signature: ...................................................................................................................
Date: _____/_____/______
Signature of prescribed witness ...................................................................................
Full name of prescribed witness ..................................................................................
Address of prescribed witness .....................................................................................
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6. Certificate under section 19 of the Powers of Attorney Act 2003
I, ................................................................................................................................
[insert full name]
certify the following:
a) I explained the effect of this power of attorney to the principal before it was signed.
b) The principal appeared to understand the effect of this power of attorney.
c) I am a prescribed witness.
d) I am not an attorney under this power of attorney.
e) I have witnessed the signature of this power of attorney by the principal.
Signature: ...................................................................... Date: _____/_____/
______
Tick the appropriate category
❏ Australian legal practitioner,
❏ Registrar of the Local Court,
❏ Licensed Conveyancer who has successfully completed a course of study
approved by the Minister,
❏ NSW Trustee and Guardian employee who has successfully completed a
course of study approved by the Minister,
❏ A trustee company employee who has successfully completed a course of
study approved by the Minister,
❏ Legal Practitioner qualified in a country other than Australia who is instructed
and employed independently of any legal practitioner appointed as an attorney
under this power of attorney.
7. Acceptance by attorney
a) I accept that I must always act in the principal’s best interests.
b) I accept that as attorney I must keep my own money and property separate from
the principal’s money and property.
c) I accept that I should keep reasonable accounts and records of the principal’s
money and property.
d) I accept that unless expressly authorised, I cannot gain a benefit from being an
attorney.
e) I accept that I must act honestly in all matters concerning the principal’s legal and
financial affairs.
Failure to do any of the above may incur civil and/or criminal
penalties.
Signature: ...................................................................... Date: _____/_____/______
Name: .............................................................................................................................
And
Signature: ...................................................................... Date: _____/_____/______
Name: .............................................................................................................................
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