Victorian Numbered Regulations Victorian Numbered RegulationsFor Form 5 in Schedule 1 to the Principal Regulations substitute —
" FORM 5
APPOINTMENT OF SUPPORTIVE ATTORNEY
Name of principal:
Address of principal:
APPOINTMENT
I appoint [ insert name of one or more supportive attorney ] of [ insert address(es) of supportive attorney(s) ] to act as my supportive attorney(s)
*and I appoint [ insert name(s) of one or more alternative supportive attorney ] of [ insert address(es) of alternative supportive attorney(s) ] as alternative supportive attorney for [ insert name of one supportive attorney ].
*and I appoint [ insert name of one alternative supportive attorney ] of [ insert address of alternative supportive attorney ] as alternative supportive attorney for [ insert names of more than one supportive attorney ].
AUTHORISATION
I authorise my supportive attorney(s) to exercise the following power(s):
*Information power in accordance with section 87 of the Powers of Attorney Act 2014 .
*Communication power in accordance with section 88 of the Powers of Attorney Act 2014 .
*Power to give effect to decisions in accordance with section 89 of the Powers of Attorney Act 2014 .
I authorise my supportive attorney(s) to exercise these powers in relation to the following matters:
*personal matters
*financial matters
*both personal and financial matters
*the following personal, financial or other matters only: [ specify ]
COMMENCEMENT
This supportive attorney appointment commences:
*on its making.
*from the time, in the circumstance or on the occasion specified as follows:
Signed : [ signature of principal or person signing at the direction of (on behalf of) the principal ]
*I sign this supportive attorney appointment 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 supportive attorney appointment form in my presence; and
*[ If witnessing another person signing at the direction of (on behalf 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 supportive attorney appointment form 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 making this supportive attorney appointment.
Each witness states that:
• I am not a supportive attorney under this appointment.
*[ If witnessing another person signing this supportive attorney appointment form at the direction of (on behalf 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 person authorised to witness statutory declarations ]
Second witness: [ signature of second witness ]
*Qualification: [ if second witness is acting as a person authorised to witness statutory declarations ]
Date:
STATEMENT OF ACCEPTANCE OF APPOINTMENT—SUPPORTIVE ATTORNEY
Name of supportive attorney:
Address of supportive attorney:
I accept my appointment as supportive attorney under this supportive attorney appointment and state that:
• I am eligible under the Powers of Attorney Act 2014 to act as a supportive attorney under a supportive attorney appointment; and
• I understand the obligations of a supportive attorney under the Powers of Attorney Act 2014 and the consequences of failing to comply with the Powers of Attorney Act 2014 ; and
• I undertake to act in accordance with 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 supportive attorney ]
Date:
Witnessed by:
Name of witness:
Address of witness:
I witnessed the signing of the statement of acceptance by the supportive attorney.
Signed : [ signature of witness ]
Date:
Note: Each supportive attorney must sign a statement of acceptance and it must be witnessed separately in the supportive attorney appointment.
STATEMENT OF ACCEPTANCE OF APPOINTMENT—ALTERNATIVE SUPPORTIVE ATTORNEY
Name of alternative supportive attorney:
Address of alternative supportive attorney:
I accept my appointment as an alternative supportive attorney under this supportive attorney appointment and state that:
• I am eligible under the Powers of Attorney Act 2014 to act as a supportive attorney under a supportive attorney appointment; and
• I understand the obligations of a supportive attorney under the Powers of Attorney Act 2014 and the consequences of failing to comply with the Powers of Attorney Act 2014 ; and
• I undertake to act in accordance with the Powers of Attorney Act 2014 ; and
• I understand the circumstances in which the alternative supportive attorney is authorised to act under the Powers of Attorney Act 2014 ; and
• I am prepared to act in place of the supportive attorney for whom I am appointed 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 supportive attorney ]
Date:
Witnessed by:
Name of witness:
Address of witness:
I witnessed the signing of the statement of acceptance by the alternative supportive attorney.
Signed : [ signature of witness ]
Date:
Note: Each alternative supportive attorney must sign a statement of acceptance and it must be witnessed separately in the supportive attorney appointment.
*Delete if not applicable.".