Editable PDF: Form 55B: Statement of Particulars
Form 55B
An Chúirt Chuarda
The Circuit Court
Record Number: …
Capacity Application: Statement of Particulars
Part 5 of the Assisted Decision-Making (Capacity) Act 2015, as amended
This form must be completed for all applications.
All information provided must be verified by affidavit
- Details of the Relevant Person:
Name: … Date of Birth: …
Phone Number: … Marital/civil partnership status: …
- Relationship of the applicant(s) to the Relevant Person:
What is the applicant’s relationship or connection to the Relevant Person or the capacity in which the applicant makes the application? (Please select one)
- I am the Relevant Person
- The Director
- The spouse or civil partner of the Relevant Person
- A decision-making assistant for the Relevant Person
- A decision-making representative for the Relevant Person
- The co-habitant of the Relevant Person
- A co-decision-maker for the Relevant Person
- A designated healthcare representative for the Relevant Person
- An attorney acting under an enduring power of attorney for the Relevant Person
- A child of the Relevant Person who has attained the age of 18 years
- A person specified for that purpose in an existing order of the court under this Part where the application relates to that order
- A person / body prescribed by Ministerial regulations under section 36(4)(k)
- If the application relates, whether in whole or in part, to the Relevant Person’s capacity to make a decision to consent to being married or to being in a civil partnership
- a registrar within the meaning of section 17 of the Civil Registration Act 2004
- the other party to the proposed marriage or civil partnership (if any), as the case may be, of the Relevant Person
- If the applicant’s relationship type is not listed in the previous section:
Has consent from the Court been given under section 36(3) of the Assisted Decision-Making (Capacity) Act 2015?
- Yes
- No
Where consent has been given by the Court, a copy of the court order must be exhibited to the grounding affidavit.
Explain the applicant’s interest in the Relevant Person’s welfare: ….
Circumstances of Application
This must be completed for all applications
- Previous discussions:
Has the applicant discussed or considered the making of this application with the Relevant Person?
- Yes
- No
Please give details including their response, if any: …..
Has the applicant(s) discussed or considered the making of this application with any other person(s) mentioned in B above?
- Yes
- No
Please give details including their response, if any: …
- Details of the Relevant Person:
Set out a summary of the material facts (and identify the source of any such information) relevant to this application which will assist the Court in making a declaration as to the capacity of the Relevant Person.
Please provide information in relation to the following if relevant to the application:
The health of the Relevant Person (example: eyesight, hearing, dietary requirements): …
The current living arrangements and individual circumstances of the Relevant Person (example: do they live at home, alone or with someone, and if so, have they a carer or other support? Are they in a hospital or nursing home?): …
Is the Relevant Person currently or have they ever been a ward of court?
- Yes
- No
If yes, please give details: …
Any other information about the Relevant Person which may be relevant to the determination of this application: …
- Benefits of this application:
Explain the benefit to the Relevant Person sought to be achieved by this application: ….
- Reasons for this application:
In the case of an application under Part 5 of the Assisted Decision-Making (Capacity) Act 2015, explain the reason why the benefit to the Relevant Person sought to be achieved has failed to be achieved in any other appropriate, practicable and less intrusive manner (example: assisted decision-making; co-decision-making) taken prior to the making of this application: ….
Explain the reason why you believe that no other appropriate, practicable and less intrusive manner to achieve that benefit (example: assisted decision-making; co-decision-making) remains to be taken prior to the making of this application: ….
- Any relevant agreements, instruments or court orders affecting the Relevant Person:
To the best of your knowledge, has the Relevant Person created any of the following:
A decision-making assistance agreement
- Yes
- No
A co-decision-making agreement
- Yes
- No
An enduring power of attorney under the ADMC Act 2015
- Yes
- No
An enduring power of attorney under the Powers of Attorney Act 1996
- Yes
- No
An advance healthcare directive
- Yes
- No
To the best of your knowledge, has either of the following been made in relation to the Relevant Person:
A decision-making representation order
- Yes
- No
A decision-making order
- Yes
- No
If you answered yes to any of the above, please give details: …
If you have a copy of any such agreement, instrument or court order, a copy must be exhibited to the grounding affidavit.
- Please set out what you understand of the Relevant Person’s past and present will and preferences in relation to the application being made.
..… - To your knowledge, does the Relevant Person have any beliefs or values which should be taken into consideration?
- Yes
- No
If yes, please give details: …
Personal Welfare Decisions
It is only necessary to complete this section of the form where your application includes an application for a declaration that the Relevant Person lacks capacity to make one or more than one decision relating to their personal welfare.
- Please identify any particular needs the Relevant Person may have in relation to the making of decisions about their personal welfare:
Examples include:
• Accommodation, including whether or not the Relevant Person should live in a designated centre (i.e. a residential institution for persons with dependencies or disabilities or a nursing home)
• Participation in employment, education or training
• Decisions on any social services provided or to be provided to the Relevant Person
• Healthcare
• Participation in social activities
• Participation in healthcare / social care research
• Other matters relating to the Relevant Person’s well-being
……………..
You should exhibit copies of all relevant correspondence and documents which may be relevant to the needs identified. Those copies shall be incorporated in a single exhibit, indexed and numbered sequentially in chronological order.
Property and Affairs Decisions
It is only necessary to complete this section of the form where your application includes an application for a declaration that the Relevant Person lacks capacity to make one or more than one decision relating to their property and affairs.
If the application is being made in relation to a particular property or transaction only, and not to the Relevant Person’s property and affairs generally, it is only necessary to provide details of the property to which the application relates or of the matters to which the transaction relates.
- Please identify any particular needs the Relevant Person may have in relation to the making of decisions about the following:
The custody, control and management of some or all of the Relevant Person’s property or property rights. Please give details: ….
The sale, exchange, mortgaging, charging, gift or other disposition of the Relevant Person’s property (example: whether you believe it might become necessary to sell the Relevant Person’s home or other assets to meet the cost of accommodation or care) Please give details: ….
The acquisition of property by the Relevant Person, or on his or her behalf. Please give details: ….
The carrying on, on behalf of the Relevant Person, of any profession, trade or business which may lawfully be carried on by a person other than the Relevant Person (example: the management of any business which the Relevant Person owns or operates which he or she might not in future be able to undertake). Please give details: ….
The making of a decision which will have the effect of dissolving a partnership in which the Relevant Person is a partner. Please give details: ….
The carrying out of any contract entered into by the Relevant Person. Please give details: ….
The discharge of the Relevant Person’s debts, tax and duty liabilities and obligations or other obligations. Please give details: ….
The execution or exercise of any of the powers or discretions vested in the Relevant Person as a tenant for life. Please give details: ….
Providing, to the extent that the Relevant Person might have been expected to do so, for the needs of a decision-making assistant, a co-decision-maker, an attorney, a designated healthcare representative or a decision-making representative for the Relevant Person or of other persons. Please give details: ….
The conduct of proceedings before any court or tribunal, whether in the name of the Relevant Person or on his or her behalf. Please give details: ….
Making an application for housing, social welfare or other benefits or otherwise protecting or advancing the interests of the Relevant Person in relation to those matters. Please give details: ….
- Please provide a summary, so far as you know, of the nature and approximate value of the Relevant Person’s assets:
Description of asset: Estimated value (€):
……………………………………………………. ………………………………..
……………………………………………………. ………………………………..
Total Estimated value (€) ………………………………..
Are any of these assets subject to a mortgage, charge or third party rights?
- Yes
- No
If yes, please give details: …..
- Please provide a summary, so far as you know, of the nature and approximate value of the Relevant Person’s liabilities:
Description of liability: Estimated value (€):
……………………………………………………. ………………………………..
……………………………………………………. ………………………………..
Total Estimated value (€) ………………………………..
- Please provide a summary, so far as you know, of the nature and approximate amount of the Relevant Person’s monthly income (indicating the source where known to you):
Description of income: Estimated value (€):
……………………………………………………. ………………………………..
……………………………………………………. ………………………………..
Total Estimated value (€) ………………………………..
- Please provide a summary, so far as you know, of the nature and approximate amount of the Relevant Person’s monthly spending:
Description of expense: Estimated cost (€):
……………………………………………………. ………………………………..
……………………………………………………. ………………………………..
Total Estimated cost(€) ………………………………..
- Please provide a summary of the Relevant Person’s dependants (people they look after financially):
Number of dependants under 18 years of age (if any): ….
Other dependants (give details): ….
Possible Co Decision-Maker
- Possible Co-Decision Maker:
If the Court declares that the Relevant Person lacks capacity, unless the assistance of a suitable person as a co-decision-maker (CDM) is made available to him or her, to make one or more than one decision specified in the Court’s declaration relating to his or her personal welfare or property and affairs, or both, do you know of a suitable person who would be willing to act as a co-decision-maker for the Relevant Person?
- Yes
- No
If you answered yes to the above, complete below:
Name(s) of suitable person(s): ….
Address(es) of suitable person(s): ….
Relationship(s) to the Relevant Person: ….
If any person proposed to act as a CDM has confirmed his or her consent to act as such, a copy of the consent must be exhibited to the grounding affidavit.
Please give reasons why that person would be suitable as a Co-Decision Maker: …..
Possible Decision-Making Representative
- Possible Decision-Making Representative
If the Court declares that the Relevant Person lacks capacity, even if the assistance of a suitable person as a co-decision-maker (CDM) is made available to him or her, to make one or more than one decision specified in the Court’s declaration relating to his or her personal welfare or property and affairs, or both, do you know of a suitable person who would be willing to act as a decision making representative (DMR) for the Relevant Person?
- Yes
- No
If you answered yes to the above, complete below:
Name(s) of suitable person(s): ….
Address(es) of suitable person(s): ….
Email of suitable person(s): ….
Phone Number of suitable person(s): ….
Relationship(s) to the Relevant Person: ….
If any person proposed to act as a DMR has confirmed his or her consent to act as such, a copy of the consent must be exhibited to the grounding affidavit.
When considering the suitability of a person to be a decision-making representative for a relevant person, the court shall have regard to the following:
• The known will and preferences of the relevant person
• The desirability of preserving existing relationships within the family of the Relevant Person
• The relationship (if any) between the relevant person and the proposed representative
• The compatibility of the proposed representative and the relevant person
• Whether the proposed representative will be able to perform the functions to be vested in him or her
• Any conflict of interest
Where the court appoints a decision-making representative to make decisions on the relevant person’s property and affairs, it shall have regard to the following
• The size, nature and complexity of the relevant person’s financial affairs
• Any professional expertise, qualification or experience required to manage the relevant person’s financial affairs
• The capability of the proposed representative to manage the relevant person’s property and affairs
• The financial expertise and support available to the proposed representative
Please give reasons why that person would be suitable as a decision-making representative: ……
Declaration sought of lawfulness of proposed intervention
- Complete this section of the form if you have included in your application that:
You are asking for declaration as to the lawfulness of an intervention proposed to be made in respect of the Relevant Person, under section 37(3) of the Act.
For the purposes of an application under section 37(3) of the Act, an ‘intervention’ means an action taken under the Assisted Decision-Making Capacity Act 2015 by:
• A decision-making assistant, co-decision-maker, decision-making representative, attorney or designated healthcare representative
• The Director of the Decision Support Service
• A special visitor or general visitor
• A healthcare professional
• Court Friend
• A person found suitable by the Court to assist the Relevant Person
Does the applicant wish the Court to make a declaration as to the lawfulness of any intervention proposed in relation to the Relevant Person, and if so, provide details of the proposed intervention …….
- Additional information for your application:
Please provide any additional information not already provided above, to which you believe the Court should have regard in considering your application ……….
- Signatures:
Signature of applicant(s)/Solicitor for applicant(s): ……
Date: ….
Solicitor Details (if applicable)
Name and Address of Solicitor: ….
Email: …. Phone Number: ….
The statement of particulars must be verified by an affidavit (Form 55I). When served on the relevant person, a form of reply (Form 55C) should also be served.