This Plain Web format version of the form is for information purposes only. To complete this, print out the accompanying PDF version of this form, complete the PDF version and then send it to the Guardianship Tribunal.
========================================================= PERSON WHO MADE THE ENDURING GUARDIANSHIP APPOINTMENT
('THE APPOINTOR') ========================================================= NAME: Mr/Mrs/Ms/Miss/Dr: _________________________________________________________ Given names: _________________________________________________________ Family name: _________________________________________________________ DATE OF BIRTH: _________________________________________________________ AGE: _________________________________________________________ CURRENT ADDRESS: _________________________________________________________ Suburb: _________________________________________________________ State: _________________________________________________________ Postcode: _________________________________________________________ TELEPHONE: Daytime: _________________________________________________________ After hours: _________________________________________________________ Mobile: _________________________________________________________ Fax No: _________________________________________________________ Pager No: _________________________________________________________ Email: _________________________________________________________ Does 'the appointor' know about the application? [ ] Yes [ ] No [ ] Don't know What is their attitude to the application? [ ] Support [ ] Oppose [ ] Don't know The Tribunal must take into consideration the views of 'the appointor' the application is about. The Tribunal always wants the appointor to come to the hearing unless that is impossible due to ill-health or some other special reason. ========================================================= YOUR DETAILS (APPLICANT) ========================================================= NAME: Mr/Mrs/Ms/Miss/Dr: _________________________________________________________ Given names: _________________________________________________________ Family name: _________________________________________________________ CURRENT ADDRESS: _________________________________________________________ Suburb: _________________________________________________________ State: _________________________________________________________ Postcode: _________________________________________________________ TELEPHONE: Daytime: _________________________________________________________ After hours: _________________________________________________________ Mobile: _________________________________________________________ Fax No: _________________________________________________________ Pager No: _________________________________________________________ Email: _________________________________________________________ Are you the appointor's: [ ] enduring guardian (please attach copy of the enduring
guardianship appointment form) If you are not the appointor's enduring guardian, what is
your relationship to the appointor?
Relationship: _________________________________________________________ ========================================================= DETAILS ABOUT THE ENDURING GUARDIANSHIP APPOINTMENT TO BE
REVIEWED ========================================================= Note: The Guardianship Tribunal must be supplied with at
least a copy of the enduring guardianship appointment and
the original wherever possible before it can deal with this
application. If you do not have a copy of the enduring
guardianship appointment and cannot obtain one, you should
contact the Tribunal to discuss this further before lodging
this application. The Tribunal must be provided with all the details about
the enduring guardianship appointment which you are seeking
to have reviewed. If there is more than one appointment, then
you must supply a copy of all the current enduring guardianship
appointments. Attach an additional sheet to this application
and give details (as below) of any additional enduring
guardianship appointments. Is there more than one enduring guardian? [ ] Yes [ ] No [ ] Don't know If yes, complete the details below for each enduring guardian. What is the date of the enduring guardianship appointment (ie.date
that the appointor signed the enduring guardianship appointment)? _________________________________________________________ Who was appointed as enduring guardian? Provide details below. NAME: Mr/Mrs/Ms/Miss/Dr: _________________________________________________________ Given names: _________________________________________________________ Family name: _________________________________________________________ CURRENT ADDRESS: _________________________________________________________ Suburb: _________________________________________________________ State: _________________________________________________________ Postcode: _________________________________________________________ TELEPHONE: Daytime: _________________________________________________________ After hours: _________________________________________________________ Mobile: _________________________________________________________ Fax No: _________________________________________________________ Pager No: _________________________________________________________ Email: _________________________________________________________ Relationship to the appointor? _________________________________________________________ Relationship to any other appointed enduring guardian? _________________________________________________________ If there are two enduring guardians, please provide details of
the second enduring guardian below.
If there are more than two enduring guardians, then attach an
additional sheet giving details for each additional enduring
guardian. NAME: Mr/Mrs/Ms/Miss/Dr: _________________________________________________________ Given names: _________________________________________________________ Family name: _________________________________________________________ CURRENT ADDRESS: _________________________________________________________ Suburb: _________________________________________________________ State: _________________________________________________________ Postcode: _________________________________________________________ TELEPHONE: Daytime: _________________________________________________________ After hours: _________________________________________________________ Mobile: _________________________________________________________ Fax No: _________________________________________________________ Pager No: _________________________________________________________ Email: _________________________________________________________ Relationship to the appointor? _________________________________________________________ Relationship to any other appointed enduring guardian? _________________________________________________________ If there are two or more enduring guardians, were they appointed to act: [ ] Jointly [ ] Severally [ ] Jointly and severally [ ] Don't know Witnesses to the execution of the enduring guardianship appointment. Who witnessed the execution of the enduring guardianship appointment?
Provide details below. NAME: Mr/Mrs/Ms/Miss/Dr: _________________________________________________________ Given names: _________________________________________________________ Family name: _________________________________________________________ CURRENT ADDRESS: _________________________________________________________ Suburb: _________________________________________________________ State: _________________________________________________________ Postcode: _________________________________________________________ TELEPHONE: Daytime: _________________________________________________________ After hours: _________________________________________________________ Mobile: _________________________________________________________ Fax No: _________________________________________________________ Pager No: _________________________________________________________ Email: _________________________________________________________ If there was more than one witness, provide their details below. Provide details of any others who were present when the
enduring guardianship appointment was executed. NAME: Mr/Mrs/Ms/Miss/Dr: _________________________________________________________ Given names: _________________________________________________________ Family name: _________________________________________________________ CURRENT ADDRESS: _________________________________________________________ Suburb: _________________________________________________________ State: _________________________________________________________ Postcode: _________________________________________________________ TELEPHONE: Daytime: _________________________________________________________ After hours: _________________________________________________________ Mobile: _________________________________________________________ Fax No: _________________________________________________________ Pager No: _________________________________________________________ Email: _________________________________________________________ NAME: Mr/Mrs/Ms/Miss/Dr: _________________________________________________________ Given names: _________________________________________________________ Family name: _________________________________________________________ CURRENT ADDRESS: _________________________________________________________ Suburb: _________________________________________________________ State: _________________________________________________________ Postcode: _________________________________________________________ TELEPHONE: Daytime: _________________________________________________________ After hours: _________________________________________________________ Mobile: _________________________________________________________ Fax No: _________________________________________________________ Pager No: _________________________________________________________ Email: _________________________________________________________ ========================================================= NATURE OF 'THE APPOINTOR'S' DISABILITIES: ========================================================= What disability does the appointor have? [ ] Dementia [ ] Intellectual disability [ ] Stroke [ ] Alcohol/drug related [ ] Mental Illness [ ] Brain Injury [ ] Other How severe or advanced is the disability?: _________________________________________________________ Approximately how long has the appointor had the disability?: _________________________________________________________ ========================================================= CONTACT DETAILS FOR WRITTEN REPORTS ========================================================= The Guardianship Tribunal will need at least two written reports about the appointor's disability. As the applicant, you are responsible for providing one or more reports from doctors or others about the appointor's capacity to make lifestyle decisions. Please provide the names of health
professionals involved below. NAME: Mr/Mrs/Ms/Miss/Dr: _________________________________________________________ Given names: _________________________________________________________ Family name: _________________________________________________________ ADDRESS: _________________________________________________________ _________________________________________________________ Suburb: _________________________________________________________ State: _________________________________________________________ Postcode: _________________________________________________________ TELEPHONE: Daytime: _________________________________________________________ After hours: _________________________________________________________ Mobile: _________________________________________________________ Fax No: _________________________________________________________ Pager No: _________________________________________________________ Email: _________________________________________________________ [ ] Report forwarded [ ] Report requested & to follow NAME: Mr/Mrs/Ms/Miss/Dr: _________________________________________________________ Given names: _________________________________________________________ Family name: _________________________________________________________ ADDRESS: _________________________________________________________ _________________________________________________________ Suburb: _________________________________________________________ State: _________________________________________________________ Postcode: _________________________________________________________ TELEPHONE: Daytime: _________________________________________________________ After hours: _________________________________________________________ Mobile: _________________________________________________________ Fax No: _________________________________________________________ Pager No: _________________________________________________________ Email: _________________________________________________________ [ ] Report forwarded [ ] Report requested & to follow If you would like to add more names please attach an extra sheet. Has the appointor ever been assessed by an Aged Care Assessment Team
or other specialist? [ ] Yes [ ] No [ ] Don't know If yes, please provide the Aged Care Assessment Team member's or
specialist's details: NAME: Mr/Mrs/Ms/Miss/Dr: _________________________________________________________ Given names: _________________________________________________________ Family name: _________________________________________________________ ADDRESS: _________________________________________________________ _________________________________________________________ Suburb: _________________________________________________________ State: _________________________________________________________ Postcode: _________________________________________________________ TELEPHONE: Daytime: _________________________________________________________ After hours: _________________________________________________________ Mobile: _________________________________________________________ Fax No: _________________________________________________________ Pager No: _________________________________________________________ Email: _________________________________________________________ [ ] Report forwarded [ ] Report requested & to follow ========================================================= OTHER INFORMATION WHICH MAY ASSIST THE TRIBUNAL ========================================================= Please identify the appointor's cultural background as this may help the Tribunal to understand the appointor and their situation. For example, Aboriginal/Koori, Greek, Vietnamese. _________________________________________________________ Does the appointor speak a language other than English at home? [ ] Yes [ ] No If yes, what language? _________________________________________________________ Does the appointor identify as an Aboriginal/Torres Strait Islander? [ ] Yes [ ] No ========================================================= WHY DO YOU THINK A REVIEW OF THE ENDURING GUARDIANSHIP
APPOINTMENT IS NEEDED? ========================================================= Please explain what led you to make this application. Do you think that the enduring guardianship appointment is
not working in the best interests of the appointor? If so,
state why you think that.
For example, are there real problems in how the appointor’s
lifestyle decisions are being handled? Is the enduring
guardian unwell or having real difficulty carrying out their
responsibilities?
_________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ What attempts have already been made to resolve these problems? _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ IMPORTANT NOTE: The Guardianship Tribunal can convert an
application for review of an enduring guardianship appointment
to an application for guardianship or financial management at
any time, if the Tribunal decides that this is appropriate
in the circumstances.
This means that the Tribunal may then decide to appoint a
guardian or financial manager for the appointor - either
the Public Guardian or a private guardian or the Protective
Commissioner or private financial manager. ========================================================= WHO DO YOU SUGGEST AS THE REPLACEMENT GUARDIAN? ========================================================= If you wish to suggest a replacement enduring guardian please
provide details below. NAME: Mr/Mrs/Ms/Miss/Dr: _________________________________________________________ Given names: _________________________________________________________ Family name: _________________________________________________________ CURRENT ADDRESS: _________________________________________________________ Suburb: _________________________________________________________ State: _________________________________________________________ Postcode: _________________________________________________________ TELEPHONE: Daytime: _________________________________________________________ After hours: _________________________________________________________ Mobile: _________________________________________________________ Fax No: _________________________________________________________ Pager No: _________________________________________________________ Email: _________________________________________________________ Relationship to the appointor? _________________________________________________________ Does this person know about this application? [ ] Yes [ ] No [ ] Don't know ========================================================= CONTACT LIST OF ALL OTHER INTERESTED PERSONS ========================================================= Staff of the Tribunal may contact people named in the application and other people who could provide information to help the Tribunal. Please name any people not already mentioned who you think may have information which could help the Tribunal (eg. close friends, relatives etc). Include anyone who may be affected by the application and particularly anyone who may be opposed to the application. NAME: Mr/Mrs/Ms/Miss/Dr: _________________________________________________________ Given names: _________________________________________________________ Family name: _________________________________________________________ ADDRESS: _________________________________________________________ Suburb: _________________________________________________________ State: _________________________________________________________ Postcode: _________________________________________________________ TELEPHONE: Daytime: _________________________________________________________ After hours: _________________________________________________________ Mobile: _________________________________________________________ Fax No: _________________________________________________________ Pager No: _________________________________________________________ Email: _________________________________________________________ Relationship to the appointor: _________________________________________________________ What is their likely attitude to this application? [ ] Support [ ] Oppose [ ] Don't know. NAME: Mr/Mrs/Ms/Miss/Dr: _________________________________________________________ Given names: _________________________________________________________ Family name: _________________________________________________________ ADDRESS: _________________________________________________________ Suburb: _________________________________________________________ State: _________________________________________________________ Postcode: _________________________________________________________ TELEPHONE: Daytime: _________________________________________________________ After hours: _________________________________________________________ Mobile: _________________________________________________________ Fax No: _________________________________________________________ Pager No: _________________________________________________________ Email: _________________________________________________________ Relationship to the appointor: _________________________________________________________ What is their likely attitude to this application? [ ] Support [ ] Oppose [ ] Don't know. NAME: Mr/Mrs/Ms/Miss/Dr: _________________________________________________________ Given names: _________________________________________________________ Family name: _________________________________________________________ ADDRESS: _________________________________________________________ Suburb: _________________________________________________________ State: _________________________________________________________ Postcode: _________________________________________________________ TELEPHONE: Daytime: _________________________________________________________ After hours: _________________________________________________________ Mobile: _________________________________________________________ Fax No: _________________________________________________________ Pager No: _________________________________________________________ Email: _________________________________________________________ Relationship to the appointor: _________________________________________________________ What is their likely attitude to this application? [ ] Support [ ] Oppose [ ] Don't know. NAME: Mr/Mrs/Ms/Miss/Dr: _________________________________________________________ Given names: _________________________________________________________ Family name: _________________________________________________________ ADDRESS: _________________________________________________________ Suburb: _________________________________________________________ State: _________________________________________________________ Postcode: _________________________________________________________ TELEPHONE: Daytime: _________________________________________________________ After hours: _________________________________________________________ Mobile: _________________________________________________________ Fax No: _________________________________________________________ Pager No: _________________________________________________________ Email: _________________________________________________________ Relationship to the appointor: _________________________________________________________ What is their likely attitude to this application? [ ] Support [ ] Oppose [ ] Don't know. If you consider the problems detailed in this application pose an immediate threat to the appointor, their health or
wellbeing and you believe this application should be given
priority over other applications, please provide your reasons. _________________________________________________________ _________________________________________________________ ========================================================= PARTIES TO A HEARING ========================================================= Parties is a term used in the Guardianship Act. 'Parties'
must be given a copy of this application and a copy of the
enduring guardianship appointment before the hearing of the
review. The Tribunal will invite all the parties to the
hearing. The parties to a review of an enduring guardianship
appointment are:
* you, the applicant
* the appointor
* any person appointed by the appointor as his/her enduring
guardian
* any other person joined by the Tribunal as a party to the
review proceedings.
========================================================= SPECIAL NEEDS AT HEARING ========================================================= Name any party to the application who needs a language
interpreter at the hearing. _________________________________________________________ If so, which language? _________________________________________________________ Name any party to the application who has a hearing
impairment and will require assistance at the hearing
(eg. signing interpreter, hearing loop etc). _________________________________________________________ If so, what help is needed? _________________________________________________________ Is any other type of help needed at the hearing
(eg. wheelchair)? _________________________________________________________ If so, what help is needed? _________________________________________________________ ========================================================= DECLARATION BY APPLICANT ========================================================= It is an offence to make a false or misleading statement in an application. Penalty up to $500. I have read and understood the application form, including
the notes contained in it. Also, I have read this completed
application and believe that to the best of my knowledge
all of the information provided is true, complete and
accurate.
Signature of applicant: _________________________________________________________ Signature of witness: _________________________________________________________ Date: _________________________________________________________ Name of witness (please print): _________________________________________________________ Address of witness: _________________________________________________________
Address: 2a Rowntree Street, Balmain, NSW, 2041
Postal Address: Locked Mailbag 9, Balmain NSW 2041
Phone: (02) 9555 8500
Fax: (02) 9555 9049
Tollfree: 1800 463 928
Email: gt@gt.nsw.gov.au
Website: www.gt.nsw.gov.au