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 welfare

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).

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.

Section 5 - What Attorney can act on

Section 6 - Consultation with others

Section 7 - Providing Information

Section 8 - Additional Terms and Conditions