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LPA
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Particulars of donors
Particulars of donee 1
Particulars of donee 2
Replacement donee
Powers granted
SECTION 1: PARTICULARS OF DONOR
(to be filled by Donor, the person making the LPA)
What is your full name as in NRIC/FIN/Passport
What is your Identification Type?
NRIC
FIN
Passport Number
What is your Identification Number?
What is your date of birth?
What is your Email Address?
What is your contact (ie telephone) number?
What is your mailing address in Singapore?
Explanation:
You may grant to your donee powers for :
Personal welfare only
Property Affairs only
BOTH Personal welfare AND Property and Affairs.
Personal Welfare means your donee decides where you should live and he/she can handle your mail/letters whilst Property Affairs means your donee is able to buy, sell, rent or mortgage your property and operate your bank accounts.
If you lose your mental capacity what do you want donees to be able to do (please tick 1 box only) :
Manage your Personal welfare only
Manage your Property and Affairs only
Manage BOTH your Personal welfare AND Property and Affairs
SECTION 2.1: PARTICULARS OF DONEE 1
What is your Donee 1’s full name as in NRIC/FIN/Passport
What is Donee 1’s Identification type?
NRIC
FIN
Passport Number
What is Donee 1’s Identification number?
What is Donee 1’s date of birth?
What is Donee 1’s email address?
What is Donee 1’s contact (ie telephone) number?
What is Donee 1’s relationship to you?
- Please select -
' +'
Father
' +'
Mother
' +'
Husband
' +'
Wife
' +'
Partner
' +'
Friend
' +'
Son
' +'
Daughter
' +'
Brother
' +'
Sister
' +'
Uncle
' +'
Aunt
' +'
Nephew
' +'
Niece
' +'
Father-in-law
' +'
Mother-in-law
' +'
Brother-in-law
' +'
Sister-in-law
' +'
Other
The Donee 1 is my...
What is Donee 1’s mailing address in Singapore?
If you lose your mental capacity what do you want Donee 1 to be able to do (please tick 1 box only) :
Manage your Personal welfare only
Manage your and Property Affairs only
Manage BOTH your Personal welfare AND Property and Affairs
SECTION 2.2: PARTICULARS OF DONEE 2
Do you wish to appoint a second Donee?
Yes
No
What is your Donee 2’s full name as in NRIC/FIN/Passport
What is Donee 2’s Identification type?
NRIC
FIN
Passport Number
What is Donee 2’s Identification number?
What is Donee 2’s date of birth?
What is Donee 2’s email address?
What is Donee 2’s contact (ie telephone) number?
What is Donee 2’s relationship to you?
- Please select -
' +'
Father
' +'
Mother
' +'
Husband
' +'
Wife
' +'
Partner
' +'
Friend
' +'
Son
' +'
Daughter
' +'
Brother
' +'
Sister
' +'
Uncle
' +'
Aunt
' +'
Nephew
' +'
Niece
' +'
Father-in-law
' +'
Mother-in-law
' +'
Brother-in-law
' +'
Sister-in-law
' +'
Other
The Donee 2 is my...
What is Donee 2’s mailing address in Singapore?
If you lose your mental capacity what do you want Donee 2 to be able to do (please tick 1 box only) :
Manage your Personal welfare only
Manage your Property and Affairs only
Manage BOTH your Personal welfare AND Property and Affairs
SECTION 3.1: PARTICULARS OF REPLACEMENT DONEE
(to be filled by Donor)
Do you wish to appoint a Replacement Donee in case either of the Donees you appoint decides not to continue to act as your Attorney, passes away, loses his mental capacity, becomes a bankrupt (if given Property and Affairs powers) or divorces you or your marriage is annulled?
Yes
No
What is your Replacement Donee’s full name as in NRIC/FIN/Passport
What is Replacement Donee’s Identification type?
NRIC
FIN
Passport Number
What is Replacement Donee’s Identification number?
What is Replacement Donee’s date of birth?
What is Replacement Donee’s email address?
What is Replacement Donee’s contact (ie telephone) number?
What is Replacement Donee’s relationship to you?
- Please select -
' +'
Father
' +'
Mother
' +'
Husband
' +'
Wife
' +'
Partner
' +'
Friend
' +'
Son
' +'
Daughter
' +'
Brother
' +'
Sister
' +'
Uncle
' +'
Aunt
' +'
Nephew
' +'
Niece
' +'
Father-in-law
' +'
Mother-in-law
' +'
Brother-in-law
' +'
Sister-in-law
' +'
Other
The Replacement Donee is my...
What is Replacement Donee’s mailing address in Singapore?
If any Donee is unable to act do you want your Replacement Donee to be authorised to replace (please tick 1 box only) :
a. only a donee with Personal Welfare powers who needs replacing
b. only a donee with Property Affairs powers who needs replacing
c. any donee who is unable to act
d. Donee 1 only
e. Donee 2 only
SECTION 4: POWERS GRANTED TO DONEE (S)
(to be filled by Donor)
Personal Welfare
Do you allow your donee (s) to give or refuse consent to start or continue your treatments, including clinical trials? Clinical trials involve the testing of new health substances such as medication or medical devices. (please tick 1 box only)
Yes
No
If you have appointed more than one donee with Personal Welfare powers, please select how they should act for you: (please tick 1 box only)
Jointly and severally
(Any one of your donees can make decisions for you.)
Jointly
(All decisions must be agreed by both donees. If they are unable to agree on a particular issue, then both donees cannot act on your behalf for that issue.)
Not applicable (only 1 donee appointed)
Explanation:
If you select Jointly be aware that:
if either of your donees is overseas it may prevent your other donee from doing anything for you until the other returns from overseas.
If you appoint 2 donees to act jointly and they disagree on the what treatment to agree or not agree to it is unclear how the doctors will act in that case.
Property and Affairs
Do you require your donee (s) to seek the court’s approval to sell, transfer, mortgage, or otherwise deal with and affect your interest in your residential property? (please tick 1 box only)
No, the one (s) does/do not need to seek the court’s approval.
Yes, for the property at this address
Do you allow your donee (s) to sell your non-residential property and make gifts on your behalf? (please tick 1 box only)
No
Yes, and I do not wish to specify the value of the gift(s) that can be made. However, the remaining cash must be sufficient to cater for my financial support.
Yes, but the total value of gift(s) shall not exceed $
within one calendar year.
If you have appointed more than one donee with Property and Affairs powers, please select how they should act for you: (please tick 1 box only)
Jointly and severally
(Any one of your donees can make decisions for you.)
Jointly
(All decisions must be agreed by both donees. If they are unable to agree on a particular issue, then both donees cannot act on your behalf for that issue.)
Not applicable (only 1 donee appointed)
Explanation:
If you select Jointly be aware that if either of your donees is overseas it may prevent your other donee from doing anything for you until the other returns from overseas.
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