File Number

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	ACT CIVIL AND ADMINISTRATIVE TRIBUNAL

APPLICATION FOR APPOINTMENT OF GUARDIAN AND/OR MANAGER
		
	*Guardianship and Management of Property Act 1991		

I, _________________________________________________
                                 (Name of Applicant)

of ________________________________________________
                                (Address)

Telephone: (Home) _______________________________  
                    (Work) _______________________________  
                   (Mobile) ______________________________

                   (EMAIL)______________________________

Wish to apply for an order of the ACT Civil and Administrative Tribunal

*1.	 For the appointment of a guardian		
	(A person to make decisions relating a person’s health and welfare)

and/or

*2. 	For the appointment of a manager	
	(A person to make decisions about property and financial matters)

* Tick or cross  box for order sought

Details and information relating to the person for whom the order is being sought:

Mr/Ms/Mrs/Miss: ________________________________________________________________
________________________________________________________________
             (Given Names) 		                 (Surname)

Address: _________________________________________________________
______________________________________ Postcode: __________________

Telephone: 
(Home) ___________________________________ 
(Work) ____________________________________ 
(Mobile) ___________________________________

(EMAIL)___________________________________

Date of Birth:	_______/_______/_________

Does the person require an interpreter?	Yes/No

If yes, please specify language: 

________________________________________________________

Is the person residing in temporary respite accommodation?        Yes/No

If yes, please specify:

Please detail the nature of the physical, mental, psychological or intellectual condition or state you believe impairs the decision-making ability of the person in respect of their health or welfare and/or financial affairs:

_____________________________________________________________________

This application should be accompanied, if possible, by a medical/psychological/other professional report(s) giving details of the person’s condition and how it affects his or her ability to make decisions about his or her personal circumstances and/or finances.

Name of doctor/psychologist/other professional involved with the person: 

Address: _____________________________________________________________________

_______________________________________________Postcode ______________ 

Phone ________________________

 Report attached  	 Report to be forwarded 	 No reports available

List any health, welfare or community agencies who are or have recently been involved (for example: Aged Care Assessment Team, Intellectual Disability Service, ADACAS, Citizen Advocacy, etc)

RELATIVES AND FRIENDS

You must include particulars of any primary carer, the person’s domestic partner, parents, brothers, sisters and each child of the person as well as other close relatives
(Attach sheet with additional names if required)

Mr/Ms/Mrs/Miss _________________________________________________________
_______________________________________________________________________
         (Given Names)				      (Surname)  

Address: _______________________________________________________________________

___________________________________________Postcode ____________________

Telephone: 
                (Home) _______________________________ 

                (Work)________________________________ 

                (Mobile) ______________________________

               (EMAIL)_______________________________

Relationship to the person for whom the order
 is sought (eg mother, domestic partner) 			_________________________

Mr/Ms/Mrs/Miss _________________________________________________________
_______________________________________________________________________
         (Given Names)				        (Surname)  

Address: _______________________________________________________________________

____________________________________________Postcode ____________________

Telephone: 
                (Home) ______________________________ 

                (Work)_______________________________ 

                (Mobile) _____________________________

               (EMAIL)______________________________

Relationship to the person for whom the order 
is sought (eg mother, domestic partner) 			__________________________
DETAILS OF PROPOSED GUARDIAN
 & CONSENT TO ACT
(A person to make lifestyle or non-financial decisions)
(If more than one, attach a sheet to this form)

  Public Advocate
                OR
OTHER

Mr/Ms/Mrs/Miss _________________________________________________________
_________________________________________________________
                     (Given Names)			          (Surname)  
Address: _____________________________________________________________________

_________________________________________Postcode ____________________

Telephone: 
                (Home) ____________________________ 

                (Work)_____________________________ 

                (Mobile) ___________________________

                (EMAIL)______________________________

Age ________________ 

Relationship to the person for whom the order is sought (eg mother, domestic partner) ___________________

I am prepared to act as *plenary/limited guardian of 

_____________________________________________________________________
                       (Name of person in respect of whom the order is sought)

if appointed by the ACT Civil and Administrative Tribunal.

Signature of Proposed Guardian________________________________ 
                                     
                                                       Date ____/_____/______
* Strike out whichever does not apply

DETAILS OF PROPOSED FINANCIALMANAGER &
 CONSENT TO ACT
(A person to make decision about property and financial matters)
(If more than one, attach a sheet to this form)
  Public Trustee
            OR
OTHER

Mr/Ms/Mrs/Miss _____________________________________________________________________
_____________________________________________________________________
                     (Given Names)			         (Surname)  
Address: _____________________________________________________________________

_________________________________________Postcode ____________________

Telephone: 
                (Home) ____________________________ 

                (Work)_____________________________ 

                (Mobile) ___________________________

               (EMAIL)____________________________

Age ________________ 

Relationship to the person for whom the order is sought (eg mother, domestic partner) ___________________

I am prepared to act as *plenary/limited manager of 

_____________________________________________________________________
                            (Name of person in respect of whom the order is sought)

if appointed by the ACT Civil and Administrative Tribunal.

Signature of Proposed Manager________________________________ 
 
                                                      Date ____/_____/______
* Strike out whichever does not apply

ENDURING POWER OF ATTORNEY

Has the person for whom an order is sought signed an Enduring Power of Attorney?

 Yes 	 No 	 Don’t Know

If yes, indicate the name and address of the person in whose favour the Enduring Power of Attorney was given:

Please attach a copy of the Enduring Power of Attorney.  The Tribunal has power, upon application and under section 75 of the Powers of Attorney Act 2006, to affect the continued operation of an Enduring Power of Attorney where it is satisfied that it is not in the best interests of the donor of the power for the power to continue.

Are you applying for the Enduring Power of Attorney to be revoked/varied?

 Yes 	 No 	 Not applicable

Have you informed the person for whom the order is being sought that you are making this application?

 Yes 	  No

Notices giving details of the time and place of the hearing will be sent to the proposed protected person and all parties listed in this application.

Please explain what particular problems led you to make this application and why you think the person needs a guardian and/or manager:

DECLARATION BY THE APPLICANT

I have read this completed application and consider to the best of my knowledge, that all the information provided is true and correct, is not misleading and that no information relevant to the application and to the Tribunal has been omitted.

Warning: pursuant to section 338 of the Criminal Code 2002, a person commits an offence if they knowingly make a statement in a document which is false or misleading to a person who is exercising a function under a territory law for which the maximum penalty is100 penalty units, imprisonment for 1 year or both.

Signature of Applicant  ___________________________________	

Date ____/____/_____

Signature of Witness 	  ___________________________________	

Date ____/____/_____

Print Name of Witness ____________________________________________________________