Advance Personal Plan – Northern Territory

Enduring Power of Attorney – Northern Territory
Order Form

1Donor

2Decision Maker(s)

3Appointment Options

4Restrictions, Requirements & Directions

5Advance Care Decisions

6Advance Care Statements

7Additional Comments

8Revocation of POA

9Payment

Donor
The Donor is the person who is appointing a decision maker under Advance Personal Plan.
Full Name*
First Middle Last
Alias (if any)
Email*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth*
DD slash MM slash YYYY

Restrictions, Requirements & Directions
Note: Decision makers may be appointed subject to restrictions on authority, requirements to be complied with or specific directions. For example, “My decision makers are not authorised to invest in XYZ Pty Ltd shares” or “If I need nursing home care, I want my decision makers to try XYZ nursing home first” or “My decision maker must consult XYZ when making decisions in relation to my health care”.

If you do not wish to provide any restrictions, requirements or directions, please select ‘none’. Otherwise, we have provided some examples of restrictions, requirements and directions. If suitable, you may select any of them. If you wish to provide other restrictions, requirements or directions, please contact us.
- None
- My decision maker must provide copies of all records and accounts in relation my financial matters to the following person
Name*
First Middle Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Relationship with donor
Please specify
- My decision maker is to consult with an individual before agreeing to the sale of my property
Identify property*
Name*
First Middle Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Relationship with donor
Please specify
- My decision maker must provide details of all important decisions about my health care and welfare they have made to:
Name*
First Middle Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Relationship with donor
Please specify
- My decision maker must consult an individual on any important decisions about my health and welfare.
Name*
First Middle Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Relationship with donor
Please specify
- Before agreeing to move me to a nursing home or facility, my decision maker must consult with:
Name*
First Middle Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Telephone*
Email*
- If I require long-term care in a facility outside my home
- I would prefer to live close to:
Name*
First Middle Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Relationship with Donor
Please specify
- I want my attorney to try this nursing home first.
Name of nursing home*

Advance Care Statement
I: GENERAL STATEMENTS OF VIEWS, WISHES AND BELIEFS

You may include in this section things that matter to you, which you think may be relevant when you can no longer speak for yourself. We have provided some examples below. If suitable, you may select any of them. If you wish to include other wishes, please contact us. If you do not wish to include any views, wishes and beliefs, please leave this section blank.
- Being able to communicate with my family is very important to me.
- To be treated with dignity by being kept clean and comfortable and having adequate pain management.
- I desire that my attorney arrange for someone to visit me on a regular basis.
Name*
First Middle Last
Relationship with Donor
Please specify
- I desire that my attorney arrange for me to attend activity/place on a regular basis.
Activity/Place*
II: GOALS FOR END OF LIFE CARE

(Include what you hope for most when you are near the end of your life. For example, family presence, access to items of significance, music, any personal, religious or cultural practices to be followed).

We have provided some examples below. If suitable, you may select any of them. If you wish to include other goals, please contact us. If you do not wish to include any goals for end of life, please leave this section blank.

If I am nearing death, I want the following:
- All my family members to be present.
- I do not wish someone to be present.
Name
First Last
- I desire this practice to be followed.
Personal, religious or cultural practices*

Payment
Service Fee*
Price:
inclusive of GST
Payment Option
- Pay now
- I already have a direct debit agreement established with SuperGuardian
Credit Card*

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name

Donor

Decision Maker(s)

Decision Maker 1

Matters

Limited matters - Financial

Limited matters - Care or welfare (including health care)

Decision Maker 2

Matters

Limited matters - Financial

Limited matters - Care or welfare (including health care)

Decision Maker 3

Matters

Limited matters - Financial

Limited matters - Care or Welfare (including health care)

Decision Maker 4

Matters

Limited matters - Financial

Limited matters - Care or Welfare (including health care)

Appointment Options for Decision Maker

Restrictions, Requirements & Directions

Advance Care Decisions

Advance Care Statement

Additional Comments

Revocation of Power of Attorney

Payment