Victorian Numbered Regulations Victorian Numbered RegulationsFor Form 1 in Schedule 1 to the Principal Regulations substitute —
" FORM 1
ENDURING POWER OF ATTORNEY
Name of principal:
Address of principal:
APPOINTMENT
I appoint [ insert name of one or more persons or position ] of [ insert address(es) of persons or position ]
*to be my attorney
*to be my joint attorneys
*to be my several attorneys
*to be my joint and several attorneys
*to be my majority attorneys
* and I appoint [ insert name of one or more persons or position ] of [ insert address(es) of persons or position ] as alternative attorney for [ insert name of one attorney ].
* and I appoint [ insert name of one person or position ] of [ insert address of person or position ] as alternative attorney for [ insert names of more than one attorney ].
Note: Under section 31(3) of the Act, an alternative attorney must act in the same manner as the attorney for whom the alternative attorney is appointed to act unless you provide otherwise.
AUTHORISATION
I authorise my attorney(s):
*to do anything on my behalf that I can lawfully do by an attorney.
*to do anything on my behalf that I can lawfully do by an attorney for—
∗ personal matters only.
∗ financial matters only.
∗ the following specified matters:
*REVOCATION
*I specify that the enduring power of attorney made by me on [ insert date made if known ] is not revoked by this enduring power of attorney.
*I specify that the following parts of the enduring power of attorney made by me on [ insert date made if known ] are not revoked by this enduring power of attorney.
Note: Under section 55 of the Act, an enduring power of attorney is revoked by a later enduring power of attorney of the principal, unless the principal specifies otherwise in the later enduring power of attorney.
Under sections 152 and 153 of the Act, an enduring power of attorney is taken to include an existing enduring power of attorney made under the Instruments Act 1958 and an existing appointment of an enduring guardian made under the Guardianship and Administration Act 1986 .
COMMENCEMENT
The powers under this enduring power of attorney for all matters are exercisable:
*immediately on the making of this enduring power of attorney.
*when I cease to have decision making capacity for the matter(s).
*from the time, in the circumstance or on the occasion specified as follows:
*CONDITIONS AND INSTRUCTIONS
The exercise of power under this enduring power of attorney is subject to the following conditions or instructions:
Signed : [ signature of principal or person signing at the direction of (on behalf of) the principal ]
*I sign this enduring power of attorney at the direction of and in the presence of the principal.
*Name of person signing at direction of principal:
*Address of person signing at direction of principal:
Date:
CERTIFICATE OF WITNESSES
Witnessed by:
Name of first witness:
Address of first witness:
Name of second witness:
Address of second witness:
Each witness certifies that:
*the principal appeared to freely and voluntarily sign this instrument in my presence; and
*[ If witnessing another person signing at the direction of and in the presence of the principal ] in my presence, the principal appeared to freely and voluntarily direct the person to sign for the principal and that person signed this instrument in my presence and in the presence of the principal; and
• at that time, the principal appeared to me to have decision making capacity in relation to the making of this enduring power of attorney; and
• I am not an attorney under this enduring power of attorney; and
• I am not a relative of the principal or of an attorney under this enduring power of attorney; and
• I am not a care worker or accommodation provider for the principal.
*[ If witnessing another person signing this enduring power of attorney at the direction of and in the presence of the principal ] I am not the person who is signing at the direction of the principal.
Signed :
First witness: [ signature of first witness ]
*Qualification: [ if first witness is acting as a medical practitioner or person authorised to witness affidavits ]
Second witness: [ signature of second witness ]
*Qualification: [ if second witness is acting as a medical practitioner or person authorised to witness affidavits ]
Date:
STATEMENT OF ACCEPTANCE OF APPOINTMENT—ATTORNEY
Name of attorney:
Address of attorney:
I accept my appointment as attorney under this enduring power of attorney and state that:
• I am eligible under Part 3 of the Powers of Attorney Act 2014 to act as an attorney under an enduring power of attorney; and
• I understand the obligations of an attorney under an enduring power of attorney and under the Powers of Attorney Act 2014 and the consequences of failing to comply with those obligations; and
• I undertake to act in accordance with the provisions of the Powers of Attorney Act 2014 that relate to enduring powers of attorney.
*[ If appointed for financial matters and you have been convicted or found guilty of an offence involving dishonesty ] I have disclosed to the principal that I have been convicted or found guilty of an offence involving dishonesty.
Signed : [ signature of attorney ]
Date:
*Position : [ if appointed as the occupant of a position ]
Witnessed by:
Name of witness:
Address of witness:
I witnessed the signing of the statement of acceptance by the attorney.
Signed : [ signature of witness ]
Date:
Note: Each attorney must sign a statement of acceptance and it must be witnessed separately in the enduring power of attorney.
STATEMENT OF ACCEPTANCE OF APPOINTMENT—ALTERNATIVE ATTORNEY
Name of alternative attorney:
Address of alternative attorney:
I accept my appointment as an alternative attorney under this enduring power of attorney and state that:
• I am eligible under Part 3 of the Powers of Attorney Act 2014 to act as an attorney under an enduring power of attorney; and
• I understand the obligations of an attorney under an enduring power of attorney and under the Powers of Attorney Act 2014 and the consequences of failing to comply with those obligations; and
• I undertake to act in accordance with the provisions of the Powers of Attorney Act 2014 that relate to enduring powers of attorney; and
• I understand the circumstances in which the alternative attorney is authorised to act under the Powers of Attorney Act 2014 ; and
• I am prepared to act in place of the attorney for whom I am appointed, if still eligible to act as attorney, when authorised to do so under the Powers of Attorney Act 2014 .
*[ If appointed for financial matters and you have been convicted or found guilty of an offence involving dishonesty ] I have disclosed to the principal that I have been convicted or found guilty of an offence involving dishonesty.
Signed : [ signature of alternative attorney ]
Date:
*Position : [ if appointed as the occupant of a position ]
Witnessed by:
Name of witness:
Address of witness:
I witnessed the signing of the statement of acceptance by the alternative attorney.
Signed : [ signature of witness ]
Date:
Note: Each alternative attorney must sign a statement of acceptance and it must be witnessed separately in the enduring power of attorney.
*Delete if not applicable.".