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<p style="line-height:18.0pt;font-size:12.0pt;line-height:18.0pt;font-family:Times New Roman;color:#000000;text-align:Left;">Keep all pages of this form together.<br/><br/><span style="font-style:normal;font-weight:bold;font-size:30.0pt;line-height:45.0pt;">Enduring Power of Attorney</span><span style="font-style:normal;font-weight:bold;font-size:30.0pt;line-height:45.0pt;"><br/><br/></span><span style="font-style:normal;font-weight:bold;font-size:30.0pt;line-height:45.0pt;">Appointment</span>
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<p style="line-height:18.0pt;font-size:12.0pt;line-height:18.0pt;font-family:Times New Roman;color:#000000;text-align:Left;">This enduring power of attorney is made under Part 3 of the <span style="font-style:normal;font-weight:bold;">Powers of Attorney Act 2014</span> and has effect as a deed under section 81 of the Act.<br/><br/><span style="font-style:normal;font-weight:bold;font-size:18.0pt;line-height:27.0pt;">Section 1: Principal (You)</span>
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<p style="line-height:18.0pt;font-size:12.0pt;line-height:18.0pt;font-family:Times New Roman;color:#000000;text-align:Left;">The person making this enduring power of attorney is known as the ‘principal’.<br/>Whenever you see the word ‘principal’ in this form, it means you.<br/><br/>
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<p style="font-size:12.0pt;line-height:18.0pt;font-family:Times New Roman;color:#000000;text-align:Left;"><span style="font-style:normal;font-weight:bold;">Name of Principal</span><br/>Alan Leslie Forbes<br/><br/><span style="font-style:normal;font-weight:bold;">Residential address</span><br/>32 Derham Street, Port Melbourne, Victoria
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<p style="font-size:12.0pt;line-height:18.0pt;font-family:Times New Roman;color:#000000;text-align:Left;"><span style="font-style:normal;font-weight:bold;">Revocation of previous enduring powers of attorney</span><br/>Under section 55 of the Powers of Attorney Act 2014 any other enduring power of attorney made by you will be revoked by this Power of Attorney, unless you specify otherwise.<br/><br/>Under sections 152 and 153 of the Powers of Attorney Act 2014 an enduring power of attorney is taken to include an existing enduring power of attorney made under the Powers of Attorney Act 2014 or the Instruments Act 1958 and an existing appointment of an enduring guardian made under the Guardianship and Administration Act 1986.<br/><br/>Please select <span style="font-style:normal;font-weight:bold;">one</span> option<br/><br/>I specify that all previous enduring powers of attorney made by me are revoked. .............. [ X ]<br/><br/><span style="font-style:normal;font-weight:bold;">OR</span><br/><br/>I specify that all the previous enduring powers of attorney made by me that are listed below are not revoked. .............. [ ]<br/><br/><br/>
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<p style="line-height:18.0pt;font-size:12.0pt;line-height:18.0pt;font-family:Times New Roman;color:#000000;text-align:Left;"><span style="font-style:normal;font-weight:bold;font-size:18.0pt;line-height:27.0pt;">Section 2: Your Attorney</span>
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<p style="font-size:12.0pt;line-height:18.0pt;font-family:Times New Roman;color:#000000;text-align:Left;"><span style="font-style:normal;font-weight:bold;">What decisions can this attorney make?</span><br/>You can specify the matters for which you authorise your attorney to act on your behalf <span style="font-style:normal;font-weight:bold;">(Option A) </span>or you can authorise your attorney to do anything on your behalf <span style="font-style:normal;font-weight:bold;">(Option B). </span>If you select Option A, you must also select the matter(s) that you authorise.<br/><br/>Please select <span style="font-style:normal;font-weight:bold;">one</span> option<br/><br/><span style="font-style:normal;font-weight:bold;">Option A: Specify the matter(s) </span>................... [ ]<br/>I authorise my attorney to do anything on my behalf that I can lawfully do by an attorney<span style="font-style:normal;font-weight:bold;"> for the matter(s) specified below.</span><br/><br/>Please select <span style="font-style:normal;font-weight:bold;">any</span> that apply:<br/><br/>Only personal matters ................................ [ ]<br/>Only financial matters ................................ [ ]<br/>The following specified matter(s) .............. [ ]<br/><br/><br/><br/><br/><span style="font-style:normal;font-weight:bold;">OR</span><br/><br/><span style="font-style:normal;font-weight:bold;">Option B: Do anything</span> .............................. [ X ]<br/>I authorise my attorney to do <br/><span style="font-style:normal;font-weight:bold;">anything</span> on my behalf that I can lawfully do by an attorney.
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<p style="font-size:12.0pt;line-height:18.0pt;font-family:Times New Roman;color:#000000;text-align:Left;">The next two pages allow you to appoint an attorney and an alternative attorney (if required). You also need to specify what decisions your attorney can make.
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<p style="font-size:12.0pt;line-height:18.0pt;font-family:Times New Roman;color:#000000;text-align:Left;">I appoint the person listed below as my attorney.<br/><br/><span style="font-style:normal;font-weight:bold;">Name of attorney</span><br/>(Insert your attorney’s name or business name, if appointing a company. Insert position, if appointing the occupant of a position.)<br/>Elise Jane Bufton<br/><br/><span style="font-style:normal;font-weight:bold;">Residential or business address</span><br/>32 Derham Street, Port Melbourne, Victoria
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<p style="font-size:12.0pt;line-height:18.0pt;font-family:Times New Roman;color:#000000;text-align:Left;"><span style="font-style:normal;font-weight:bold;">Do you want to appoint an alternative attorney for this attorney?</span><br/>No ...... [ ] Go to ‘Do you want to appoint <br/> another attorney?’ at the end of<br/> this page<br/><br/>Yes ...... [ X ] Provide details<br/><br/>I appoint the person listed below as my alternative attorney.<br/><br/><span style="font-style:normal;font-weight:bold;">Name of alternative attorney</span><br/>(Insert business name, if appointing a company.)<br/>Janet Lesley Forbes<br/><br/><span style="font-style:normal;font-weight:bold;">Residential or business address</span><br/>3 Howard Road, Dingley Village, Victoria<br/><br/>Note: Under section 31(3) of the <span style="font-style:normal;font-weight:bold;">Power of Attorney Act 2014</span>, an alternative attorney must act in the same manner as the attorney for whom the alternative attorney is appointed to act unless you provide otherwise.
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<p style="font-size:12.0pt;line-height:18.0pt;font-family:Times New Roman;color:#000000;text-align:Left;"><span style="font-style:normal;font-weight:bold;">When can your alternative attorney act?</span><span style="font-style:normal;font-weight:bold;"><br/></span><span style="font-style:normal;font-weight:bold;">You can specify below when your alternative attorney can act. If you do not specify, an alternative attorney can only take the place of the attorney if:</span><span style="font-style:normal;font-weight:bold;"><br/></span>• the attorney is unable or unwilling to act<br/>• the appointment of your attorney is revoked (cancelled) because they are no longer eligible to be your attorney (for example, the attorney becomes your care worker or health provider).<br/><br/><br/><br/><br/><span style="font-style:normal;font-weight:bold;">Do you want to appoint another attorney?</span><br/>Yes ..... [ ] Go to next page<br/><br/>No ..... [ X ] Go to Section 4
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<p style="line-height:18.0pt;font-size:12.0pt;line-height:18.0pt;font-family:Times New Roman;color:#000000;text-align:Left;"><span style="font-style:normal;font-weight:bold;font-size:18.0pt;line-height:27.0pt;">Section 3: How your attorneys can act</span><br/><br/>You can choose how your attorneys are to act when they make a decision for you.<br/><br/>You can also choose whether they act differently for personal and financial matters.<br/><br/>
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<p style="font-size:12.0pt;line-height:18.0pt;font-family:Times New Roman;color:#000000;text-align:Left;">Only complete this section if you have appointed more than one attorney.<br/><br/>If you do not complete this section, and you have more than one attorney, it will be assumed that you have appointed your attorneys always to act as joint attorneys (together).
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<p style="line-height:18.0pt;font-size:12.0pt;line-height:18.0pt;font-family:Times New Roman;color:#000000;text-align:Left;"><span style="font-style:normal;font-weight:bold;">How must the attorneys act?</span><br/>Please select <span style="font-style:normal;font-weight:bold;">one </span>option.<br/><br/>Act as joint attorneys (together): The attorneys must make decisions together<br/>and they must all agree. ............................................................................................................ [ X ]<br/><br/>Act as <span style="font-style:normal;font-weight:bold;">several</span> attorneys (separately): Each attorney must make decisions separately. ............ [ ]<br/><br/>Act as joint and several attorneys (act together, or act separately): The attorneys can<br/>make decisions separately but if they make a joint decision, they must all agree. ................... [ ]<br/><br/>Act by <span style="font-style:normal;font-weight:bold;">majority</span> attorneys: Where there are more than two attorneys, decisions are<br/>only made when more than half of the attorneys agree. For example, if there are three<br/>attorneys, then two out of the three must agree to a decision. .................................................. [ ]<br/><br/>If different attorneys are appointed for different matters, specify below how you wish the attorneys to act (jointly, severally, jointly and severally or by majority) and for which matters.
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<p style="line-height:18.0pt;font-size:12.0pt;line-height:18.0pt;font-family:Times New Roman;color:#000000;text-align:Left;"><span style="font-style:normal;font-weight:bold;font-size:18.0pt;line-height:27.0pt;">Section 4: Start Date</span><br/><br/>
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<p style="font-size:12.0pt;line-height:18.0pt;font-family:Times New Roman;color:#000000;text-align:Left;">If you do not complete this section, your attorney can start making decisions immediately on the making of this enduring power of attorney.
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<p style="line-height:18.0pt;font-size:12.0pt;line-height:18.0pt;font-family:Times New Roman;color:#000000;text-align:Left;"><span style="font-style:normal;font-weight:bold;">When can the attorney start making decisions?</span>
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<p style="font-size:12.0pt;line-height:18.0pt;font-family:Times New Roman;color:#000000;text-align:Left;"><span style="font-style:normal;font-weight:bold;">At the same time<br/>for all matters </span>.......................................... [ X ]<br/><br/>Please choose <span style="font-style:normal;font-weight:bold;">one </span>option.<br/><br/>Immediately on the<br/>making of this enduring<br/>power of attorney ....................... [ ]<br/><br/>When I cease to have<br/>decision making capacity<br/>for the matter(s) .......................... [ X ]<br/><br/>At any other time,<br/>circumstance or occasion ........... [ ] Specify<br/><br/>____________________
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<p style="font-size:12.0pt;line-height:18.0pt;font-family:Times New Roman;color:#000000;text-align:Left;"><span style="font-style:normal;font-weight:bold;">At different times<br/>for different matters</span>.............................. [ ]<br/><br/>Complete <span style="font-style:normal;font-weight:bold;">all</span> that apply.<br/><br/>Immediately on the<br/>making of this enduring<br/>power of attorney,<br/>for these matters ...................... [ ] <span style="font-style:italic;font-weight:bold;">Specify</span><br/><br/><br/><br/>When I cease to have<br/>decision making capacity<br/>for these matters ...................... [ ] <span style="font-style:italic;font-weight:bold;">Specify</span><br/><br/><br/><br/>At any other time,<br/>circumstance or occasion,<br/>for these matters ...................... [ ] <span style="font-style:italic;font-weight:bold;">Specify</span><br/><br/>Specify the time, circumstance or occasion:<br/><br/><br/>Specify the matters:
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<p style="line-height:18.0pt;font-size:12.0pt;line-height:18.0pt;font-family:Times New Roman;color:#000000;text-align:Left;"><span style="font-style:normal;font-weight:bold;font-size:18.0pt;line-height:27.0pt;">Section 5: Conditions and instructions (optional)</span><br/><br/>Your attorney is required to consider any conditions and/or instructions that you specify when making decisions for you. You do not have to place conditions or give instructions unless you want to.<br/><br/>The exercise of power under this enduring power of attorney is subject to the conditions and/or instructions set out below.<br/><br/><span style="font-style:normal;font-weight:bold;">Conflict transactions (optional)</span><span style="font-style:normal;font-weight:bold;"><br/><br/></span>
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<p style="font-size:12.0pt;line-height:18.0pt;font-family:Times New Roman;color:#000000;text-align:Left;">Only fill in this section if an attorney has been appointed for <span style="font-style:normal;font-weight:bold;">financial matters.</span>
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<p style="line-height:18.0pt;font-size:12.0pt;line-height:18.0pt;font-family:Times New Roman;color:#000000;text-align:Left;">Sometimes there may be a conflict between the duty of your attorney to you and an interest of their own, or of a relative, business associate or close friend. You can authorise (give permission) for your attorney to enter into transaction(s) even if there is a conflict of interest.<br/><br/>I authorise my attorney to enter into the following conflict transaction(s):<br/>All conflict of interest activities.<br/><br/><span style="font-style:normal;font-weight:bold;">Gifts (optional)</span><br/><br/>
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<p style="font-size:12.0pt;line-height:18.0pt;font-family:Times New Roman;color:#000000;text-align:Left;">Only fill in this section if an attorney has been appointed for <span style="font-style:normal;font-weight:bold;">financial matters.</span>
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<p style="line-height:18.0pt;font-size:12.0pt;line-height:18.0pt;font-family:Times New Roman;color:#000000;text-align:Left;">An attorney for financial matters can use your money or other financial assets to give a gift or donation. Gifts must be of a seasonal nature or for a special event and be made to your relatives or close friends. An attorney can also give a gift to themselves, their relatives, close friends or organisations with which they have a connection. The donation must be the type of donation made when you had capacity or that you might reasonably be expected to make. All gifts and donations must be reasonable in the circumstances, particularly having regard to your financial situation.<br/><br/>Specify any conditions or restrictions that you want to place on the making of gifts or donations.<br/><br/>
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<p style="line-height:18.0pt;font-size:12.0pt;line-height:18.0pt;font-family:Times New Roman;color:#000000;text-align:Left;"><span style="font-style:normal;font-weight:bold;">Maintenance of your dependents (optional)</span><span style="font-style:normal;font-weight:bold;"><br/><br/></span>
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<p style="font-size:12.0pt;line-height:18.0pt;font-family:Times New Roman;color:#000000;text-align:Left;">Only fill in this section if an attorney has been appointed for <span style="font-style:normal;font-weight:bold;">financial matters.</span>
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<p style="line-height:18.0pt;font-size:12.0pt;line-height:18.0pt;font-family:Times New Roman;color:#000000;text-align:Left;">You can specify in your enduring power of attorney if you want your attorney for financial matters to use your money or other financial assets to provide for the needs of one or more of your dependants (for example, one of your children). The amount made available by your attorney to maintain your dependants must not be more than what is reasonable having regard to all the circumstances, in particular your financial circumstances, unless you specify otherwise in your enduring power of attorney.<br/><br/>Specify if you want to authorise your attorney for financial matters to provide for the maintenance of your dependant(s) from your money or other financial assets and, if so, whether you want to authorise an amount that is more than what is reasonable in the circumstances.<br/><br/>I do not authorise my attorney to provide for the maintenance of my dependant(s) from my money or other financial assets.<br/><br/><span style="font-style:normal;font-weight:bold;">Payments to attorney (optional)</span><br/>An attorney is not allowed to be paid to act as your attorney, unless payment is authorised in the enduring power of attorney or by law.<br/><br/>You can authorise your attorney to be paid by specifying below how your attorney are to be paid and any limits on how much they can be paid.<br/><br/>My attorneys are not entitled to any payment for acting as my attorney other than reimbursed for out-of-pocket expenses.<br/><br/><span style="font-style:normal;font-weight:bold;">Additional conditions or instructions (optional)</span><br/>You may want to set out additional conditions and/or instructions to guide your attorney. You may also want to specify a persons to be notified by the attorney, when the attorney starts acting for you, when you no longer have decision making capacity.<br/><br/>Enter conditions and instructions below.<br/><br/>In the event of my death, you have the power to donate my organs to those in need. Subsequently, please have my remains cremated, and scattered in any maple-bush wooded forest in Ontario, Canada.<br/><br/>In the event of my medical incapacitation, you have the authority to decide if I should remain on life support, or not. I would prefer not to remain on life support if two qualified medical doctors certify that my likelihood of survival is less than 10%.
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<p style="line-height:18.0pt;font-size:12.0pt;line-height:18.0pt;font-family:Times New Roman;color:#000000;text-align:Left;"><span style="font-style:normal;font-weight:bold;font-size:18.0pt;line-height:27.0pt;">Section 6: Principal's signature</span><br/>You need to sign and date this form by hand. You must sign the form in front of two witnesses. They must then sign and date the form in front of you and each other. One witness must be a medical practitioner, or be a person who is authorised to witness affidavits. A list of people who are authorised to witness an affidavit can be found at justice.vic.gov.au/affidavit.<br/><br/>
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<p style="font-size:12.0pt;line-height:18.0pt;font-family:Times New Roman;color:#000000;text-align:Left;">If you need someone to sign for you due to a physical disability, do not fill out this section.<br/>Fill out Section A1.
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<p style="font-size:12.0pt;line-height:18.0pt;font-family:Times New Roman;color:#000000;text-align:Left;">In this section, the word ‘we’ means the witnesses. The word ‘principal’ means the person making this enduring power of attorney.<br/><br/><span style="font-style:normal;font-weight:bold;">Name of principal</span><br/>Alan Leslie Forbes<br/><br/><span style="font-style:normal;font-weight:bold;">Signature</span><br/>..................................................<br/><span style="font-style:normal;font-weight:bold;">Date</span><br/>____ ________________ ________<br/><br/><span style="font-style:normal;font-weight:bold;">Witnesses</span><br/>Each witness <span style="font-style:normal;font-weight:bold;">certifies </span>that:<br/>• the principal appeared to freely and voluntarily sign this instrument in our presence, and<br/>• at that time, the principal appeared to us to have decision making capacity in relation to making this enduring power of attorney, and<br/>• we are not attorneys under this enduring power of attorney, and<br/>• we are not relatives of the principal or of an attorney under this enduring power of attorney, and<br/>• we are not care workers or accommodation providers for the principal.
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<p style="font-size:12.0pt;line-height:18.0pt;font-family:Times New Roman;color:#000000;text-align:Left;"><span style="font-style:normal;font-weight:bold;">Name of authorised witness</span><br/>_____________________________________<br/><br/><span style="font-style:normal;font-weight:bold;">Residential or business address</span><br/>Street name and #, suburb/town, state, postcode<br/>_____________________________________<br/><br/><span style="font-style:normal;font-weight:bold;">Signature</span><br/>..........................................................................<br/><br/><span style="font-style:normal;font-weight:bold;">Qualification (as medical practitioner or person authorised to witness affidavits)</span><br/>_____________________________________<br/><br/><span style="font-style:normal;font-weight:bold;">Date</span><br/>___________ ___________ ___________<br/><br/><span style="font-style:normal;font-weight:bold;">Name of other witness</span><br/>_____________________________________<br/><br/><span style="font-style:normal;font-weight:bold;">Residential or business address</span><br/>Street name and #, suburb/town, state, postcode<br/>_____________________________________<br/><br/><span style="font-style:normal;font-weight:bold;">Signature</span><br/>..........................................................................<br/><br/><span style="font-style:normal;font-weight:bold;">Date</span><br/>___________ ___________ ___________
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<p style="line-height:18.0pt;font-size:12.0pt;line-height:18.0pt;font-family:Times New Roman;color:#000000;text-align:Left;"><span style="font-style:normal;font-weight:bold;font-size:18.0pt;line-height:27.0pt;text-decoration: line-through;">Section A1: Signed at the direction of the principal</span><br/><span style="text-decoration: line-through;">The person signing for you, at your direction, must be 18 years old or older. They cannot be an attorney under this enduring power of attorney or a witness to the signing of this enduring power of attorney. They must sign and date this form by hand. They must sign the form in front of you and two witnesses. The witnesses must then sign and date the form in front of you, the person signing at your direction and each other. One witness must be a medical practitioner, or be a person who is authorised to witness affidavits. A list of people who are authorised to witness an affidavit can be found at justice.vic.gov.au/affidavit.</span><br/><br/>
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<p style="font-size:12.0pt;line-height:18.0pt;font-family:Times New Roman;color:#000000;text-align:Left;"><span style="text-decoration: line-through;">I sign this enduring power of attorney at the direction of and in the presence of the principal.</span><span style="text-decoration: line-through;"><br/><br/></span><span style="font-style:normal;font-weight:bold;text-decoration: line-through;">Name of principal</span><span style="text-decoration: line-through;"><br/></span><span style="text-decoration: line-through;">Alan Leslie Forbes</span><span style="text-decoration: line-through;"><br/><br/></span><span style="font-style:normal;font-weight:bold;text-decoration: line-through;">Name of person signing at the direction of the principal</span><span style="text-decoration: line-through;"><br/></span><span style="text-decoration: line-through;">__________</span><span style="text-decoration: line-through;"><br/><br/></span><span style="font-style:normal;font-weight:bold;text-decoration: line-through;">Residential or business address</span><span style="text-decoration: line-through;"><br/></span><span style="text-decoration: line-through;">Street name and #, suburb/town, state, postcode</span><span style="text-decoration: line-through;"><br/></span><span style="text-decoration: line-through;">__________</span><span style="text-decoration: line-through;"><br/><br/></span><span style="font-style:normal;font-weight:bold;text-decoration: line-through;">Signature</span><span style="text-decoration: line-through;"><br/></span><span style="text-decoration: line-through;">..................................................</span><span style="text-decoration: line-through;"><br/></span><span style="font-style:normal;font-weight:bold;text-decoration: line-through;">Date</span><span style="text-decoration: line-through;"><br/></span><span style="text-decoration: line-through;">____ ________________ ________</span><span style="text-decoration: line-through;"><br/><br/></span><span style="font-style:normal;font-weight:bold;text-decoration: line-through;">Witnesses</span><span style="text-decoration: line-through;"><br/></span><span style="text-decoration: line-through;">Each witness </span><span style="font-style:normal;font-weight:bold;text-decoration: line-through;">certifies </span><span style="text-decoration: line-through;">that:</span><span style="text-decoration: line-through;"><br/></span><span style="text-decoration: line-through;">• in my presence, the principal appeared to freely and voluntarily direct the person to sign for the principal and that person signed this instrument in my presence and in the presence of the principal, and</span><span style="text-decoration: line-through;"><br/></span><span style="text-decoration: line-through;">• at that time, the principal appeared to me to have decision making capacity in relation to the making of this enduring power of attorney, and </span><span style="text-decoration: line-through;"><br/></span><span style="text-decoration: line-through;">• I am not attorney under this enduring power of attorney, and</span><span style="text-decoration: line-through;"><br/></span><span style="text-decoration: line-through;">• I am not a relative of the principal or of an attorney under this enduring power of attorney, and</span><span style="text-decoration: line-through;"><br/></span><span style="text-decoration: line-through;">• I am not a care worker or accommodation provider for the principal, and</span><span style="text-decoration: line-through;"><br/></span><span style="text-decoration: line-through;">• I am not the person who is signing at the direction of the principal.</span>
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<p style="font-size:12.0pt;line-height:18.0pt;font-family:Times New Roman;color:#000000;text-align:Left;"><span style="font-style:normal;font-weight:bold;text-decoration: line-through;">Name of authorised witness</span><span style="text-decoration: line-through;"><br/></span><span style="text-decoration: line-through;">_____________________________________</span><span style="text-decoration: line-through;"><br/><br/></span><span style="font-style:normal;font-weight:bold;text-decoration: line-through;">Residential or business address</span><span style="text-decoration: line-through;"><br/></span><span style="text-decoration: line-through;">Street name and #, suburb/town, state, postcode</span><span style="text-decoration: line-through;"><br/></span><span style="text-decoration: line-through;">_____________________________________</span><span style="text-decoration: line-through;"><br/><br/></span><span style="font-style:normal;font-weight:bold;text-decoration: line-through;">Signature</span><span style="text-decoration: line-through;"><br/></span><span style="text-decoration: line-through;">..........................................................................</span><span style="text-decoration: line-through;"><br/><br/></span><span style="font-style:normal;font-weight:bold;text-decoration: line-through;">Qualification (as medical practitioner or person authorised to witness affidavits)</span><span style="text-decoration: line-through;"><br/></span><span style="text-decoration: line-through;">_____________________________________</span><span style="text-decoration: line-through;"><br/><br/></span><span style="font-style:normal;font-weight:bold;text-decoration: line-through;">Date</span><span style="text-decoration: line-through;"><br/></span><span style="text-decoration: line-through;">___________ ___________ ___________</span><span style="text-decoration: line-through;"><br/><br/></span><span style="font-style:normal;font-weight:bold;text-decoration: line-through;">Name of other witness</span><span style="text-decoration: line-through;"><br/></span><span style="text-decoration: line-through;">_____________________________________</span><span style="text-decoration: line-through;"><br/><br/></span><span style="font-style:normal;font-weight:bold;text-decoration: line-through;">Residential or business address</span><span style="text-decoration: line-through;"><br/></span><span style="text-decoration: line-through;">Street name and #, suburb/town, state, postcode</span><span style="text-decoration: line-through;"><br/></span><span style="text-decoration: line-through;">_____________________________________</span><span style="text-decoration: line-through;"><br/><br/></span><span style="font-style:normal;font-weight:bold;text-decoration: line-through;">Signature</span><span style="text-decoration: line-through;"><br/></span><span style="text-decoration: line-through;">..........................................................................</span><span style="text-decoration: line-through;"><br/><br/></span><span style="font-style:normal;font-weight:bold;text-decoration: line-through;">Date</span><span style="text-decoration: line-through;"><br/></span><span style="text-decoration: line-through;">___________ ___________ ___________</span>
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<p style="line-height:18.0pt;font-size:12.0pt;line-height:18.0pt;font-family:Times New Roman;color:#000000;text-align:Left;"><span style="font-style:normal;font-weight:bold;font-size:18.0pt;line-height:27.0pt;">Section 7: Statement of acceptance of appointment</span><span style="font-style:normal;font-weight:bold;font-size:18.0pt;line-height:27.0pt;"><br/></span><span style="font-style:normal;font-weight:bold;font-size:18.0pt;line-height:27.0pt;">by attorney</span><span style="font-size:18.0pt;line-height:27.0pt;"><br/><br/></span>
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<p style="font-size:12.0pt;line-height:18.0pt;font-family:Times New Roman;color:#000000;text-align:Left;"><span style="font-size:11.0pt;line-height:16.5pt;">This section needs to be read and signed by each attorney being appointed. A witness must also sign the witness certificate for each attorney.</span><span style="font-size:11.0pt;line-height:16.5pt;"><br/><br/></span><span style="font-size:11.0pt;line-height:16.5pt;">This section can be completed at the same time as the principal completes their section or at a later time.</span><span style="font-size:11.0pt;line-height:16.5pt;"><br/><br/></span><span style="font-style:normal;font-weight:bold;font-size:11.0pt;line-height:16.5pt;">Attorney</span><span style="font-size:11.0pt;line-height:16.5pt;"><br/><br/></span><span style="font-style:normal;font-weight:bold;font-size:11.0pt;line-height:16.5pt;">I accept my appointment as attorney </span><span style="font-size:11.0pt;line-height:16.5pt;">for the principal under this enduring power of attorney and state that:</span><span style="font-size:11.0pt;line-height:16.5pt;"><br/><br/></span><span style="font-size:11.0pt;line-height:16.5pt;">• I am eligible under Part 3 of the </span><span style="font-style:normal;font-weight:bold;font-size:11.0pt;line-height:16.5pt;">Powers of Attorney Act 2014 </span><span style="font-size:11.0pt;line-height:16.5pt;">to act as an attorney under an enduring power of attorney, and</span><span style="font-size:11.0pt;line-height:16.5pt;"><br/></span><span style="font-size:11.0pt;line-height:16.5pt;">• I understand the obligations of an attorney under an enduring power of attorney and under the </span><span style="font-style:normal;font-weight:bold;font-size:11.0pt;line-height:16.5pt;">Powers of Attorney Act 2014 </span><span style="font-size:11.0pt;line-height:16.5pt;">and the consequences of failing to comply with those obligations, and</span><span style="font-size:11.0pt;line-height:16.5pt;"><br/></span><span style="font-size:11.0pt;line-height:16.5pt;">• I undertake to act in accordance with the provisions of the </span><span style="font-style:normal;font-weight:bold;font-size:11.0pt;line-height:16.5pt;">Powers of Attorney Act 2014 </span><span style="font-size:11.0pt;line-height:16.5pt;">that relate to enduring powers of attorney.</span><span style="font-size:11.0pt;line-height:16.5pt;"><br/><br/></span><span style="font-style:italic;font-weight:normal;font-size:11.0pt;line-height:16.5pt;">If appointed for financial matters and you have been convicted or found guilty of an offence involving dishonesty</span><span style="font-size:11.0pt;line-height:16.5pt;"><br/><br/></span><span style="font-size:11.0pt;line-height:16.5pt;">I have disclosed to the principal that<br/>I have been convicted or found guilty<br/>of an offence involving dishonesty. .......... [ ]</span>
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<p style="font-size:12.0pt;line-height:18.0pt;font-family:Times New Roman;color:#000000;text-align:Left;"><span style="font-style:normal;font-weight:bold;">Name of attorney</span><br/>Elise Jane Bufton<br/><br/><span style="font-style:normal;font-weight:bold;">Residential or business address</span><br/>32 Derham Street, Port Melbourne, Victoria<br/><br/><span style="font-style:normal;font-weight:bold;">Signature</span><br/>..........................................................................<br/><br/><span style="font-style:normal;font-weight:bold;">Date</span><br/>___________ ___________ ___________<br/><br/><span style="font-style:normal;font-weight:bold;">Witness</span><br/>I witnessed the signing of the statement of acceptance by the attorney.<br/>_____________________________________<br/><br/><span style="font-style:normal;font-weight:bold;">Name of witness</span>_____________________________________<br/><br/><span style="font-style:normal;font-weight:bold;">Residential or business address</span><br/>Street name and #, suburb/town, state, postcode<br/>_____________________________________<br/><br/><span style="font-style:normal;font-weight:bold;">Signature</span><br/>..........................................................................<br/><br/><span style="font-style:normal;font-weight:bold;">Date</span><br/>___________ ___________ ___________
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<p style="line-height:18.0pt;font-size:12.0pt;line-height:18.0pt;font-family:Times New Roman;color:#000000;text-align:Left;"><span style="font-style:normal;font-weight:bold;font-size:18.0pt;line-height:27.0pt;">Section 8: Statement of acceptance of appointment </span><span style="font-style:normal;font-weight:bold;font-size:18.0pt;line-height:27.0pt;"><br/></span><span style="font-style:normal;font-weight:bold;font-size:18.0pt;line-height:27.0pt;">by alternative attorney</span><span style="font-size:18.0pt;line-height:27.0pt;"><br/><br/></span>
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<p style="font-size:12.0pt;line-height:18.0pt;font-family:Times New Roman;color:#000000;text-align:Left;"><span style="font-size:11.0pt;line-height:16.5pt;">This section needs to be read and signed by each alternative attorney you are appointing. A witness must also sign the witness certificate for each alternative attorney.</span><span style="font-size:11.0pt;line-height:16.5pt;"><br/></span><span style="font-size:11.0pt;line-height:16.5pt;">This section can be completed at the same time as the principal completes their section or at a later time.</span><br/><br/><span style="font-style:normal;font-weight:bold;font-size:11.0pt;line-height:16.5pt;">Alternative Attorney</span><span style="font-size:11.0pt;line-height:16.5pt;"><br/></span><span style="font-style:normal;font-weight:bold;font-size:11.0pt;line-height:16.5pt;">I accept my appointment as an alternative attorney </span><span style="font-size:11.0pt;line-height:16.5pt;">under this enduring power of attorney and state that:</span><span style="font-size:11.0pt;line-height:16.5pt;"><br/></span><span style="font-size:11.0pt;line-height:16.5pt;">• I am eligible under Part 3 of the </span><span style="font-style:normal;font-weight:bold;font-size:11.0pt;line-height:16.5pt;">Powers of Attorney Act 2014 </span><span style="font-size:11.0pt;line-height:16.5pt;">to act as an attorney under an enduring power of attorney, and</span><span style="font-size:11.0pt;line-height:16.5pt;"><br/></span><span style="font-size:11.0pt;line-height:16.5pt;">• I understand the obligations of an attorney under an enduring power of attorney and under the </span><span style="font-style:normal;font-weight:bold;font-size:11.0pt;line-height:16.5pt;">Powers of Attorney Act 2014 </span><span style="font-size:11.0pt;line-height:16.5pt;">and the consequences of failing to comply with those obligations, and</span><span style="font-size:11.0pt;line-height:16.5pt;"><br/></span><span style="font-size:11.0pt;line-height:16.5pt;">• I undertake to act in accordance with the provisions of the </span><span style="font-style:normal;font-weight:bold;font-size:11.0pt;line-height:16.5pt;">Powers of Attorney Act 2014 </span><span style="font-size:11.0pt;line-height:16.5pt;">that relate to enduring powers of attorney.</span><span style="font-size:11.0pt;line-height:16.5pt;"><br/></span><span style="font-size:11.0pt;line-height:16.5pt;">• I understand the circumstances in which the alternative attorney is authorised to act under the </span><span style="font-style:normal;font-weight:bold;font-size:11.0pt;line-height:16.5pt;">Powers of Attorney Act 2014, </span><span style="font-size:11.0pt;line-height:16.5pt;">and</span><span style="font-size:11.0pt;line-height:16.5pt;"><br/></span><span style="font-size:11.0pt;line-height:16.5pt;">• I am prepared to act in place of the attorney for whom I am appointed, if still eligible to act as attorney, when authorised to do so under the </span><span style="font-style:normal;font-weight:bold;font-size:11.0pt;line-height:16.5pt;">Powers of Attorney Act 2014.</span><span style="font-size:11.0pt;line-height:16.5pt;"><br/><br/></span><span style="font-style:italic;font-weight:normal;font-size:11.0pt;line-height:16.5pt;">If appointed for financial matters and you have been convicted or found guilty of an offence involving dishonesty</span><span style="font-size:11.0pt;line-height:16.5pt;"><br/></span><span style="font-size:11.0pt;line-height:16.5pt;">I have disclosed to the principal that<br/>I have been convicted or found guilty<br/>of an offence involving dishonesty. .......... [ ]</span>
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<p style="font-size:12.0pt;line-height:18.0pt;font-family:Times New Roman;color:#000000;text-align:Left;"><span style="font-style:normal;font-weight:bold;">Name of attorney</span><br/>Janet Lesley Forbes<br/><br/><span style="font-style:normal;font-weight:bold;">Residential or business address</span><br/>3 Howard Road, Dingley Village, Victoria<br/><br/><span style="font-style:normal;font-weight:bold;">Signature</span><br/>..........................................................................<br/><br/><span style="font-style:normal;font-weight:bold;">Date</span><br/>___________ ___________ ___________<br/><br/><span style="font-style:normal;font-weight:bold;">Witness</span><br/>I witnessed the signing of the statement of acceptance by the alternative attorney.<br/>_____________________________________<br/><br/><span style="font-style:normal;font-weight:bold;">Name of witness</span>_____________________________________<br/><br/><span style="font-style:normal;font-weight:bold;">Residential or business address</span><br/>Street name and #, suburb/town, state, postcode<br/>_____________________________________<br/><br/><span style="font-style:normal;font-weight:bold;">Signature</span><br/>..........................................................................<br/><br/><span style="font-style:normal;font-weight:bold;">Date</span><br/>___________ ___________ ___________
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<p style="line-height:18.0pt;font-size:12.0pt;line-height:18.0pt;font-family:Times New Roman;color:#000000;text-align:Center;"><span style="font-style:normal;font-weight:bold;">APPOINTMENT OF MEDICAL TREATMENT DECISION MAKER</span>
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<p style="line-height:18.0pt;font-size:12.0pt;line-height:18.0pt;font-family:Times New Roman;color:#000000;text-align:Left;">I, Alan Leslie Forbes, of 32 Derham Street, Port Melbourne, Victoria make this Appointment of Medical Decision Maker (the "Appointment") on ____ ________________ ________.
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<ol start="1" style="line-height:18.0pt;font-size:12.0pt;line-height:18.0pt;font-family:Times New Roman;color:#000000;list-style:decimal;">
<li class="lhl" style="text-align:Left;margin-bottom:18.0pt;list-style:none;"><span style="font-style:normal;font-weight:bold;">Background</span><span style="color:#000000;"><br/></span>
</li>
<li style="margin-bottom:18.0pt;" value="1">This Appointment is made under the <span style="font-style:italic;font-weight:normal;">Medical Treatment Planning and Decisions Act 2016</span>.<span style="color:#000000;"><br/></span>
</li>
<li style="margin-bottom:18.0pt;" value="2">I was born on 1 January 1981.<span style="color:#000000;"><br/></span>
</li>
<li class="lhl" style="text-align:Left;margin-bottom:18.0pt;list-style:none;"><span style="font-style:normal;font-weight:bold;">Revocation</span><span style="color:#000000;"><br/></span>
</li>
<li style="margin-bottom:18.0pt;" value="3">I revoke any other previous appointment of a medical treatment decision maker however described. <span style="color:#000000;"><br/></span>
</li>
<li class="lhl" style="text-align:Left;margin-bottom:18.0pt;list-style:none;"><span style="font-style:normal;font-weight:bold;">Medical Treatment Decision Maker</span><span style="color:#000000;"><br/></span>
</li>
<li style="margin-bottom:0.0pt;" value="4">I appoint as my medical treatment decision maker Elise Jane Bufton of 32 Derham Street, Port Melbourne, Victoria, born 20 January 1979.<span style="color:#000000;"><br/></span>
</li>
</ol>
<p style="line-height:18.0pt;font-size:12.0pt;line-height:18.0pt;font-family:Times New Roman;color:#000000;text-align:Left;"><br/>IN WITNESS WHEREOF, I have signed my name on this ____ ________________ ________.
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<p style="font-size:12.0pt;line-height:18.0pt;font-family:Times New Roman;color:#000000;text-align:Left;"><br/>_______________________________________<br/>Alan Leslie Forbes's Signature
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<p style="line-height:18.0pt;font-size:12.0pt;line-height:18.0pt;font-family:Times New Roman;color:#000000;text-align:Left;">Each witness certifies that:
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<li style="margin-bottom:18.0pt;" value="1">Alan Leslie Forbes did sign this Appointment on ____ ________________ ________ in our presence, and we, in the presence of each other and Alan Leslie Forbes, all being present at the same time, sign our names as witnesses;<span style="color:#000000;"><br/></span>
</li>
<li style="margin-bottom:18.0pt;" value="2">At the time of signing this Appointment, Alan Leslie Forbes appears to have decision-making capacity and appears to understand the nature and consequences of making or revoking any previous appointment;<span style="color:#000000;"><br/></span>
</li>
<li style="margin-bottom:18.0pt;" value="3">Alan Leslie Forbes appeared to freely and voluntarily sign this Appointment;<span style="color:#000000;"><br/></span>
</li>
<li style="margin-bottom:18.0pt;" value="4">Alan Leslie Forbes signed this Appointment in my presence and in the presence of a second witness; and<span style="color:#000000;"><br/></span>
</li>
<li style="margin-bottom:0.0pt;" value="5">I am not Alan Leslie Forbes's medical treatment decision maker under this Appointment.<span style="color:#000000;"><br/></span>
</li>
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<p style="font-size:12.0pt;line-height:18.0pt;font-family:Times New Roman;color:#000000;text-align:Left;"><br/>_______________________________________<br/>Signature of authorised witness
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<p style="font-size:12.0pt;line-height:18.0pt;font-family:Times New Roman;color:#000000;text-align:Left;"><br/>_______________________________________<br/>Full name of adult witness
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<p style="font-size:12.0pt;line-height:18.0pt;font-family:Times New Roman;color:#000000;text-align:Left;"><br/>_______________________________________<br/>Full name of authorised witness
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<p style="font-size:12.0pt;line-height:18.0pt;font-family:Times New Roman;color:#000000;text-align:Left;"><br/>_______________________________________<br/>Address of adult witness
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<p style="font-size:12.0pt;line-height:18.0pt;font-family:Times New Roman;color:#000000;text-align:Left;"><br/>_______________________________________<br/>Address of authorised witness
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<p style="font-size:12.0pt;line-height:18.0pt;font-family:Times New Roman;color:#000000;text-align:Left;"><br/>_______________________________________<br/>Qualification of authorised witness (<span style="font-style:italic;font-weight:normal;">the authorised witness must be a registered medical practitioner or able to witness affidavits</span>)
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<p style="line-height:18.0pt;font-size:12.0pt;line-height:18.0pt;font-family:Times New Roman;color:#000000;text-align:Left;"><span style="font-style:normal;font-weight:bold;">STATEMENT OF ACCEPTANCE</span><br/><br/>I, Elise Jane Bufton, accept my appointment as medical treatment decision maker and state that:
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<ul style="line-height:18.0pt;font-size:12.0pt;line-height:18.0pt;font-family:Times New Roman;color:#000000;list-style:disc;">
<li style="margin-bottom:18.0pt;" value="1">I understand the obligations of an appointed medical treatment decision maker;<span style="color:#000000;"><br/></span>
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<li style="margin-bottom:18.0pt;" value="2">I undertake to act in accordance with any known preferences and values of the person making this Appointment;<span style="color:#000000;"><br/></span>
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<li style="margin-bottom:18.0pt;" value="3">I understake to promote the personal and social wellbeing of the person making this Appointment, having regard to the need to respect the person's individuality; and<span style="color:#000000;"><br/></span>
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<li style="margin-bottom:0.0pt;" value="4">I have read and understand any advance care directive that the person has given before, or at the same time, as this Appointment.<span style="color:#000000;"><br/></span>
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<p style="font-size:12.0pt;line-height:18.0pt;font-family:Times New Roman;color:#000000;text-align:Left;"><br/>_______________________________________<br/>Elise Jane Bufton's Signature
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<p style="font-size:12.0pt;line-height:18.0pt;font-family:Times New Roman;color:#000000;text-align:Left;"><br/>_______________________________________<br/>Date
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<p style="line-height:18.0pt;font-size:12.0pt;line-height:18.0pt;font-family:Times New Roman;color:#000000;text-align:Left;">I certify that I witnessed the signing of this statement of acceptance:
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<p style="font-size:12.0pt;line-height:18.0pt;font-family:Times New Roman;color:#000000;text-align:Left;">_______________________________________<br/>Signature of adult witness
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<p style="font-size:12.0pt;line-height:18.0pt;font-family:Times New Roman;color:#000000;text-align:Left;"><br/>_______________________________________<br/>Full name of adult witness
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<p style="font-size:12.0pt;line-height:18.0pt;font-family:Times New Roman;color:#000000;text-align:Left;"><br/>_______________________________________<br/>Date
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