1Intro2Donor3Attorney(s)4Successor Attorney(s)5What your Attorney can act on6Consultation7Information8Additional T&Cs Introduction This online questionnaire is designed to allow you to send us information we need to prepare your Enduring Power of Attorney for Personal Care and Welfare (EPA Personal Care and Welfare). Some quick notes on how people are referred to in this questionnaire. The EPA Personal Care and Welfare gives someone you trust the power to make decisions about your care and welfare if you’re unable to. This person is called your Attorney. The person who gives the power is called the Donor. If you are completing this on behalf of the Donor, please note we also refer to that person as “you”. There are some compulsory questions – these are noted with an asterisk (*). There is guidance and pop up information within the questionnaire to help you along. There are 8 Sections. Each Section has a General or Additional Comments field at the end. This allows you to enter anything you want, and you should feel free to use this if you have any doubts or are unsure about what is being asked in the earlier parts of the Section. If you need to take a break from the questionnaire, you can do so by clicking the Save and Continue Later link at the bottom of each page and you will receive an email with a link to allow you to resume where you left off. Your answers will all be saved automatically. Once you have completed the questionnaire click the SUBMIT button on the last page (Section 8 – Additional Terms and Conditions) and an email will be sent to you and us with your answers. We will follow up with you as required and contact you to organise how the completed EPA Personal Care and Welfare can be “executed” (signed and witnessed by all the relevant people). For further information about Enduring Power of Attorney for Personal Care and Welfare, you might want to review the following resource available from the Office of Seniors. https://www.superseniors.msd.govt.nz/documents/epa-documents/standard-explanation-epa-personal-care-and-welfare.pdf Your EPA for Personal Care and Welfare will only take effect if you become mentally incapable. This will need to be confirmed by a medical certificate or the Family Court deciding that you are mentally incapable. At any stage you can contact us with questions on 03 2189855. Section 2 - Donor Details & Previous EPAs in relation to Personal Care and Welfare In this section and the entire form, we will refer to the person giving the power of attorney as either "Donor" or "you" Name of person giving the enduring power of attorney to act in relation to personal care and welfareFirst Name(Required) Middle Name(s) Surname(Required) Gender Male Female Non-Binary Address Street Address Suburb City Post Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email(Required) Phone (Home and/or mobile)(Required) Date of Birth(Required) Day Month Year If you have a regular contact at Mee & Henry, please indicate hereLiz HenryKrista SimBrandt AuldWendy SutherlandSuzanne HendersonEmma HowieGillian KennedySheree CaseyPrevious EPAs in relation to my personal care and welfare This is my first EPA in relation to my personal care and welfare I have one or more previous EPAs in relation to my personal care and welfare which I want to revoke I have one or more previous EPAs in relation to my personal care and welfare which need to be considered alongside this EPA If you want to maintain any other EPAs in relation to your personal care and welfare please provide details of those EPAs here so we can consider whether there is any overlapping or inconsistencyIf you can, please upload a copy of all and any previous EPAs in relation to your personal care and welfare Drop files here or Select files Max. file size: 512 MB. General or Additional CommentsIf you want to add anything more related to the above questions please do so here. Section 3 - Attorney Details You can appoint only one person to be your Attorney to act on your personal care and welfare matters (although you can appoint successor attorneys).Please confirm that your chosen Attorney is: (all must apply)(Required) not less than 20 years old not bankrupt not mentally incapable First Name(Required) Middle Name Surname(Required) Address Street Address Suburb City Post Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email Contact Number Relationship to Donor (You) General or Additional CommentsIf you want to add anything more related to the above questions please do so here. Section 4 - Successor Attorney(s) Details If the appointment of your Attorney appointed in Section 3 ends, then a successor Attorney appointed may act as Attorney in their place.Do you want to appoint a successor Attorney? Yes No Unsure First Name(Required) Middle Name Surname(Required) Address Street Address Suburb City Post Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email Contact Number Relationship to Donor (You) General or Additional CommentsIf you want to add anything more related to the above questions please do so here. Section 5 - What Attorney can act onYour Attorney can act on(Required) All my personal care and welfare matters Only the matters relating to my personal care and welfare I have listed below Unsure List of MattersIs your Attorney's authority to act subject to conditions and restrictions?(Required) Yes No Unsure List of conditions and restrictionsGeneral or Additional CommentsIf you want to add anything more related to the above questions please do so here. Section 6 - Consultation with othersDo you want your Attorney(s) or successor Attorney(s) to consult with anyone else before making decisions? Yes No Unsure People to consult with First Name Surname Relationship to Donor/You Actions Edit Delete There are no People to consult with. Add Person to consult with Maximum number of people to consult with reached. General or Additional CommentsIf you want to add anything more related to the above questions please do so here. Section 7 - Providing InformationDo you want to name a person or people who your Attorney(s) need to give information to about how they are carrying out their role? Yes No Unsure Person Details First Name Surname Relationship to you Information to be given to this person Actions Edit Delete There are no People. Add Person Maximum number of people reached. General or Additional CommentsIf you want to add anything more related to the above questions please do so here. Section 8 - Additional Terms and ConditionsMy EPA is subject to the following additional terms and conditions Δ
