EPOA Questionnaire | Donovan Winkler Lawyers

About you and your family

Are you:*

Your name*

First Middle Last

Are you known by any other names?*

List the other names you are known by*

What is your residential address?*

Address Line 1 Address Line 2 City/Suburb State Postcode

What is your preferred email?

What is your preferred telephone/mobile no?

What is your date of birth?*

Your spouse's details

Your spouse's name*

First Middle Last

Is your spouse known by any other names?*

List the other names your spouse is known by*

What is your spouse's preferred email?

What is your spouse's preferred telephone/mobile no?

What is your spouse's date of birth?*

Financial Circumstances

Do you (or your spouse) have any superannuation?*

Please provide details of superannuation*

Super Fund Name	Owner/Member	Approximate Balance	Self Managed Super Fund Y/N?

Have you (or your spouse) completed binding death benefit nomination/s for your super?*

Do you (or your spouse) have an interest or shareholding in any private or family companies?*

Answer yes if you are a director, or own shares in your own name or via a trust or other family company

Please provide details of private or family companies*

Company Name	Who are the directors?	Entity that owns the shareholding	What percentage of the company is owned by that entity?	What are the key company assets/businesses?

Do you (or your spouse) have an interest in any trusts?*

Common types of trusts are family trusts, discretionary trusts, and unit trusts

Please provide details of trusts*

Name of trust	Who is the trustee?	Who is the appointor?	Type of trust	What are the key trust assets/businesses?

Do you (or your spouse) have any family agreements or arrangements?*

Examples might include intrafamily loans, granny flat arrangements, or a mutual Wills contract

Please provide details of the agreement or arrangement*

Enduring Power of Attorney details

An Enduring Power of Attorney (EPOA) is a document that allows you to appoint someone else as an attorney to make decisions for you, usually when you have lost the capacity to make decisions for yourself. Attorneys can be given the power to make financial decisions (e.g. decisions about spending money or dealing with property), personal decisions (e.g. where you live) and health decisions (e.g. medical treatment). You can decide how your attorneys must make decisions. For example, you can require attorneys to act unanimously or you can permit any one of the attorneys to make the final decision. A common method is to give one person (e.g. a spouse) the right to make decisions on their own, but to then appoint backup decision makers (e.g. a brother and sister).

Do you have an existing Enduring Power of Attorney you want to change?

How many attorneys will you be appointing?*

In your EPOA, the attorney is the name given to the person you nominate to make decisions on your behalf

Please enter a number from 1 to 4.

Who are you appointing as your attorney/s?*

Name of Person	Relationship to you	Address	Telephone/mobile no

What decisions do you want your attorney/s to have the power to make for you?*

Do you want to appoint different attorneys for financial matters to your attorneys for personal and health matters?

You do not need to appoint the same attorneys to make decisions for both financial matters and personal/health matters. If you prefer, you can appoint different attorneys for each role (i.e. because of their special knowledge or skill set). Please record these instructions below

When do you want your attorney's power to make financial decisions to begin?*

How do you want your attorneys to make decisions for you?

Is your spouse appointing the same attorneys as you?*

How many attorneys will your spouse be appointing?*

In your spouse's EPOA, the attorney is the name given to the person your spouse nominates to make decisions on his or her behalf

Please enter a number from 1 to 4.

Who is your spouse appointing as his or her attorney/s?*

Name of Person	Relationship to your spouse	Address	Telephone/mobile no

What decisions does your spouse want the attorney/s to have the power to make for him/her?*

Does your spouse want to appoint different attorneys for financial matters to their attorneys for personal and health matters?

Your spouse does not need to appoint the same attorneys to make decisions for both financial matters and personal/health matters. If your spouse prefers, they can appoint different attorneys for each role (i.e. because of their special knowledge or skill set). Please record these instructions below

When does your spouse want the attorney/s power to make financial decisions to begin?*

How does your spouse want their attorneys to make decisions for them?

Are there any terms (i.e. restrictions) or special allowances that you (or your spouse) want to apply to your attorney/s?

If yes, please record these below

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Do you (or your spouse) suffer from any condition that might currently affect your decision making capacity?*

For example, a dementia diagnosis

Please record details of the condition below*

Do you need your Enduring Power of Attorney prepared urgently?*

For example, if you have upcoming overseas travel planned, an upcoming surgery, or a serious illness

Please let us know the reason for the urgency below so that we can prioritise your matter*

Are there any other things you want us to know about your circumstances?

Please let us know about things like any children with special needs, family estrangements, if you want to discuss making an Advanced Health Directive, or anything else important to you

What else do you want us to know about?

Enduring Power of Attorney Questionnaire

About you and your family

Your spouse's details

Financial Circumstances

Enduring Power of Attorney details

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