my mandate in case of incapacity - aqdmd · the mandatary the right to exercise the powers invested...

My mandate in case of incapacityis for all adults who are of soundmind. It allows them to appoint a man-datary to ensure the protection of theirperson and the administration of theirproperty in the event that illness or anaccident deprives them of theirfaculties. It contains essentialinformation on the choice of man-datary, the various clauses thatmay be included in the mandateand its homologation.

This new edition features a com -pletely revised form, designed tooffer mandators a greater rangeof elements contributing to theirprotection.

Printed in Québec, Canada

$ 9.95

ISBN 978-2-551-19846-7

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LES PUBLICATIONS DU QUÉBEC

Mandatein Case

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of Incapacity

portée

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Mandatein Case of Incapacity

Couvert_mandate_500343_GH_Couvert 10-01-25 13:37 Page1

Mandatein CaseMandatein Case

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of Incapacityof Incapacity

LES PUBLICATIONS DU QUÉBEC1000, route de l’Église, bureau 500, Québec (Québec) G1V 3V9

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Mandat AN_16635_Mandat_AN 10-01-25 13:38 Page1

This publication was prepared by Le Curateur public du Québec

This edition was published byLes Publications du Québec1000, route de l’Église, bureau 500Québec (Québec)G1V 3V9

Project CoordinationAnn Picard

Graphic designerLucie Pouliot

ProductionPascal Couture

Wherever required by the context,any word written in the singular form also includesthe plural, and any word writtenin the masculine form also includesthe feminine.

Legal Deposit – 2010Bibliothèque et Archives nationales du QuébecLibrary and Archives CanadaISBN 978-2-551-19846-7ISBN 978-2-551-19848-1 (PDF)© Gouvernement du Québec, 2010

All rights reserved.No part of this publication may be reproduced in any manner whatsoever or translated without the authorization of Les Publications du Québec.

Bibliothèque et Archives nationales du Québecand Library and Archives Canada

cataloguing in publication

Main entry under title:

My Mandate in Case of Incapacity

9th ed.

(La justice à votre portée)Issued also in French under title: Mon mandat en cas

d’inaptitude.

ISBN 978-2-551-19846-7

1. Mandate in case of incapacity — Québec (Province).2. Capacity and disability — Québec (Province). I. Québec(Province). Curateur public. II. Series: Justice à votre portée.

KEQ233.M6613 2010 346.71401'3 C2009-942412-6


Table of Contents

What is a mandate in case of incapacity? 5

What is the difference between a will, a mandate and a power of attorney? 5

What forms can a mandate take? 6

What is homologation? 7

What to consider when choosing a mandatary? 9

What is the role of the Curateur public with regard to mandataries? 10

What happens if you regain your capacity? 11

What if the mandator dies? 11

What happens if you become incapacitated without having prepared a mandate? 12

Choosing a tutor to a minor 12

How to fill out the form 13

Explanatory notes for the form 14

Contact the Curateur public du Québec 21

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SINCE APRIL 15, 1990, THE CIVIL CODE OF QUÉBEC

HAS ALLOWED ANY ADULT OF SOUND MIND TO PRE-

PARE A MANDATE IN CASE OF INCAPACITY. IF YOU HAVE

NOT YET DRAWN UP A MANDATE BUT ARE THINKING ABOUT

DOING SO, THIS BOOKLET WILL GUIDE YOU THROUGH THE

PROCESS. IT EXPLAINS THE MAIN FEATURES OF THE MANDATE

AND ALSO CONTAINS A MANDATE FORM DESIGNED TO RESPOND

TO THE NEEDS OF AS MANY PEOPLE AS POSSIBLE. YOU CAN USE

IT AS IS OR AS THE BASIS FOR DRAFTING YOUR OWN MANDATE,

ADAPTING IT TO YOUR SITUATION SO THAT IT RESPONDS TO

YOUR NEEDS. BEFORE PROCEEDING, BE SURE TO READ THE FOL-

LOWING INFORMATION.

NoteThe text of the law always takes precedence over theinformation in this booklet.

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What is a mandate in caseof incapacity?

A mandate in case of incapacity is a document inwhich a person, known as a mandator, while infull possession of his faculties, appoints anotherperson, known as the mandatary, to see to hisprotection or administer his property or both atonce, in the event that illness or an accidentdeprives him of his faculties, either temporarilyor permanently.

Mandators are free to decide on the content of themandate. For their protection and physical well-being, mandators can include a living will tocover their end-of-life wishes. Likewise, the clausesdealing with the administration of property canbe very general or highly detailed, with a list ofspecific administrative activities, depending onthe mandator’s situation.

Finally, mandators may even appoint more thanone mandatary in their mandate. For example,they may appoint one to take care of their personand another to administer their property. Theycan also designate a substitute mandatary, incase the principal mandatary refuses to have themandate homologated, if for some reason thisindividual is unable to continue to execute themandate or dies before or during the exercise oftheir duties. Mandators may also determine abasis of remuneration for the mandatary.

What is the differencebetween a will, a mandateand a power of attorney?

A will, which contains your wishes about what isto be done with your property, takes effect onlyafter your death. A power of attorney and a man-date in case of incapacity can be used only duringyour lifetime.

A power of attorney authorizes a person to performcertain ordinary administrative tasks (pay bills, with-draw money from a bank account) or other moreserious administrative activities. A power of attorneyis used for the administration of property only. It mayor may not be notarial. If it is not notarial, it can beterminated at any time with no need for any specialprocedure. It is also terminated if its author is placed

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under protective supervision (advisorship to a per-son of full age, a tutorship or a curatorship) orbecomes incapable of supervising the actions of theperson to whom power of attorney has been given.The death of the person who has power of attorneyalso terminates it.

The mandate in case of incapacity goes further.It can cover the administration of property andalso contain provisions for the protection of themandator’s person. However, to come into force,a mandate must be homologated by the court,which must then have evidence that the manda-tor has become incapable.

What forms can a mandate take?

The law provides for two forms of mandate in caseof incapacity:

ÿ the mandate by notarial deed: a notaryprepares the document according to thewishes and needs of the mandator. Thismandate is registered with the Chambredes notaires so that it can be located easilyshould the mandator become incapable;

ÿ the mandate given in the presence ofwitnesses (with or without the pres-ence of a lawyer): it is signed by themandator in the presence of two witnesseswho have no interest in the document. Ifthe mandator has already signed the man-date, he must acknowledge his signaturein the presence of the witnesses. If themandator is physically unable to sign thedocument, the law authorizes him to haveit signed by a third party according to hisinstructions. This situation must, ofcourse, be made clear to the witnesses.The document must then be counter-signed by the two witnesses who are notthe mandataries and have no interest inthe mandate. Their signature certifies thatthe mandator was of sound mind when hesigned the mandate. Mandators do nothave to disclose the contents of their man-date to witnesses. The law simply requiresthat mandators state the nature of thedocument to be signed (by saying forexample, "this is my mandate in case ofincapacity").

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People who have given a mandate in the presence ofwitnesses should store the original in a safe place,inform the mandatary and give this individual acopy. If an attorney prepares the mandate, it will beregistered with the Barreau du Québec and beeasily found if the mandator becomes incapable.

However, whether your mandate is notarial orgiven in the presence of witnesses, it is alwaysadvisable to tell your family and those close toyou the name of your mandatary. This is a wiseprecaution because it enables them to act at onceshould you become incapable of looking afteryourself as the result of an illness or accident.

Whatever form it takes, the mandate in case ofincapacity comes into effect only after it has beenhomologated or approved by the court, inother words, examined by a clerk or judge of theSuperior Court in the legal district where themandator lives or has legal residence.

What is homologation?

Homologation is a legal procedure whereby thecourt establishes the incapacity of the mandator,verifies the existence of the mandate and itsvalidity if given in the presence of witnesses.Only the mandatary can apply to the court in themandator’s legal district for homologation of thisdocument. The application must be accompaniedby a copy of the mandate, along with medical andpsychosocial assessments establishing themandator’s incapacity. These assessments aremade by health and social services professionalsassociated with an establishment in the healthcare network (CLSC, hospital, residential andlong-term care facility, rehabilitation centre) or inprivate practice. As shown in the table on page 8,the final stage of the procedure is the judgmentgiving the mandate force of law, that is, givingthe mandatary the right to exercise the powersinvested in him.

Homologation of a mandate in case of incapacityis a formal procedure that takes time. The man-datary may use the services of legal counsel(notary or attorney).

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Mandataryinstitutes

the process

Application to court for

homologation

Notice ofapplication

Court hearing

Interviewwith personof full age

Taking into account:

ÿ validity of mandate

ÿ medical assessment

ÿ psychosocialassessment

ÿ incapacity ofperson of full age

ÿ interview withperson of full age

Notice ofjudgment

Homologationjudgment

Homologation of a mandateRegular procedure

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What to consider whenchoosing a mandatary?

Because of the responsibilities that a mandatarymay have to take on, it is useful to inform thisperson of your decision. You can then make surethat they have understood your needs before youofficially designate them. You can then discussthe powers you wish to give them over your personand property in order to be sure that they willexecute the mandate as you wish. Your choice ofmandatary and substitute mandatary, if youappoint one, is most important; in either case, itshould be a person in whom you have full confi-dence and with whom you have developed closeties. Freedom of choice is one of the major advan-tages of the mandate.

You may appoint more than one mandatary. Theenclosed form allows you to enter the name ofone person to protect your person and another(or several others, depending on the nature of theproperty to be managed) to manage your property.Note that a legal entity, such as a trust company,can be appointed, but only to administer yourproperty. It is recommended that you also desig-nate a substitute mandatary in case the man-datary you initially appointed cannot or no longerwants to perform these duties.

You can also specifically authorize a mandatary toproperty to act in your place as liquidator if youare given this office after becoming incapable.Finally, if your personal or financial situation iscomplicated, we recommend you consult a notaryor an attorney about preparing and drafting yourmandate.

In addition, there is now a process in which thenotary takes charge of handling the procedureinvolving a person who needs protective supervi-sion. Notaries must, however, have the conclu-sions of their minutes approved by the clerk or bythe court. Only certain notaries certified by theChambre des notaires are allowed to apply thisprocess. Unless the court orders otherwise, thecosts incurred to homologate the mandate are theresponsibility of the mandator.

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What is the role of theCurateur public with

regard to mandataries?

The Curateur public keeps a register of homolo-gated mandates. The information entered in thisregister includes the first and last names of themandator and mandatary and the date and num-ber of the homologation judgment.

The Curateur public also has the power to inter-vene in any legal procedure connected with thehomologation or revocation of a mandate. Forexample, it can contest the evidence of the manda-tor’s incapacity presented in the homologationprocess. In the case of revocation, it can presentreasons that it considers justify termination of themandate in favour of protective supervision.

In addition, the Curateur public has power ofinquiry over mandataries. For example, ifinformed that a mandatary is negligent or abusiveor has failed to respect the terms of the mandate,the Curateur public can investigate the situationupon receipt of a complaint. If the complaint isfounded, the Curateur public can meet with themandatary to ask for the situation to be correctedor to obtain an undertaking to do so. If the man-datary persists in being remiss and refuses toremedy the situation, the Curateur public canremove the mandatary from office by applying tothe Superior Court. In fact, any interested partycan institute this procedure.

However, the Curateur public cannot be designatedas the mandatary or the person to whom the man-datary must report periodically, as the law does notspecifically authorize it to assume these duties.

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What if the mandator dies?

The death of the mandator obviously terminatesthe mandate. If this happens, the mandatary’sreport is made to the mandator’s heirs. If the man-datary dies during the mandate, his heirs have toreport for him on his management to the substi-tute mandatary or the legal representative (tutoror curator) appointed by the court following theinstitution of protective supervision, when thereis no substitute mandatary.

What happens if youregain your capacity?

Needless to say, if you regain your health and fac-ulties, you can personally take the steps to termi-nate the mandate. Your mandatary can also dothis, as can any other interested party. The proce-dure can be instituted by a motion.

Your mandate can also be revoked on the initiativeof the director general of a health and social servi -ces establishment. The law authorizes this individualto mention, in the report containing medical andpsychosocial assessments, that you are once againcapable of looking after yourself and no longerneed to be represented by a mandatary.

This report is sent to the clerk of the court. If it isnot contested by the people notified by the clerkof the court within the 30 days following filing ofthe report, your mandate will be automaticallyrevoked. The clerk of the court gives notice inwriting of the revocation and gives copies to you,your mandatary and the Curateur public. Themandatary must then account to you for his man-agement.

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What happens if youbecome incapacitated

without having prepared a mandate?

Once incapable, a person is no longer able tomake a mandate. However, the law has provisionsfor the protection and representation of personsof full age who become incapacitated withouthaving prepared a mandate in case of incapacityand who need to be protected. These includedomestic and judicial mandates, which apply tospouses. Certain laws, such as An Act respectingthe Quebec Pension Plan and the AutomobileInsurance Act, allow an organization paying apension or indemnity to designate a person otherthan the beneficiary to manage the sums paid.

Finally, there are three forms of protective super-vision. From the most limited to the most inclu-sive, they are: advisorship to a person of fullage, tutorship to the person, the property, orboth, and curatorship, which covers both per-son and property. An advisorship to a person offull age is an essentially private type of supervi-sion that can only be conferred on the Curateurpublic under exceptional circumstances and dealsstrictly with assisting in the administration ofproperty. Tutorships and curatorships can beentrusted to the Curateur public if there is no onein the incapacitated adult’s immediate circle toassume the role of tutor or curator.

Choosing a tutor to a minor

If, at the time of the homologation of your mandate,one of your children is a minor (younger than 18),a tutor should be appointed. You can designate thisperson to assume the office of tutor to a minor nowbut this designation will take effect only if you arethe last (as father or mother) to assume the dutiesof legal tutorship.

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If you have more than one minor child, you canchoose the same tutor for all children concernedor designate several different tutors by indicatingwhich tutor will be responsible for each child con-cerned.

However, please note that in these circumstances,each child can have only one tutor.

How to fill out the form

We have provided a form allowing you to prepareyour mandate in case of incapacity. You will seethat it contains detailed information about themandator’s wishes regarding the protection of hisperson and general well-being. The clausesregarding the administration of property areespecially suited to people whose property, what-ever its value, is simple to administer. If your per-sonal and financial situation is complicated andrequires special wishes to be expressed, it ispreferable that you consult a notary or attorney.

You should review your mandate periodically.After all, it should respond to your needs. Therules of form imposed by the law must berespected, which means if you change the man-date, the whole process has to be repeated as ifyou were giving a mandate for the first time.Don’t forget that the new mandate revokes allprior mandates.

The new mandate must be signed by the manda-tor (or, at his request, by a third party, as describedearlier) in the presence of two witnesses, who mustalso sign the document attesting to the mandator’scapacity. If a third party has drawn up the mandateon behalf of the mandator and has also signed forhim, the witnesses must be formally notified of this.

The explanatory notes that follow present infor-mation that will help you complete the "MyMandate in Case of Incapacity" form.

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Explanatory notes for the form

When you choose to cross out all or part ofa clause, place your initials in the left mar-gin to clearly confirm your intention.

It is possible that you, the mandator, have alreadysigned your mandate or had it signed by a thirdparty in your presence following your instruc-tions, but without witnesses. In these cases, youmust authenticate your signature or that of thethird party who signed for you because you wereunable to sign before witnesses.

1 SINGLE MANDATARY

The mandatary you choose is a personyou trust, to whom you give responsibil-ities and powers for the protection ofyour person—care, support, etc.—andthe administration of your property. Besure that this person will be able toassume this task when you become inca-pable. For example, a spouse of thesame age may no longer be able to takecare of you, manage your assets or makedecisions about entrusting these tasks tothird parties.

The substitute mandatary is the per-son who will take over as mandatary incase your principal mandatary cannotexecute the mandate.

2 MULTIPLE MANDATARIES

Option 2 lets you appoint several man-dataries: one to protect your person andone or more to manage your property. Inthe latter case, you can choose a trustcompany or other institution authorizedby law. It is recommended that youinform it of your choice, find out its con-ditions (management fees, for example)and obtain its agreement.

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The substitute mandatary is the per-son who will take over as mandatary incase your principal mandatary cannotexecute the mandate. As you have cho-sen several mandataries, you can desig-nate one substitute for each of them. Bychecking the last box, you allow the lastremaining mandatary to continue to act:he will then act to protect your personand administer your property.

3 INVENTORY AND REPORT

Although optional, these clauses are awise precaution and will facilitate thetask of the mandatary when preparingthe final account at the end of his admin-istration.

When the person receiving the managementreport is informed of the mandatary’s admin-istration, they make sure that the decisionsconcerning both the protection of the per-son and the management of the person’sproperty have been made in the mandator’sinterest.

If this individual notices that the man-datary has been negligent in the perform-ance of their duties, they can take theappropriate steps to correct the situation.

Ideally, the person asked to receivereports from your mandatary will not bethe designated substitute who could beasked to act as the principal mandatary.If this is unavoidable, it is important todesignate a second substitute to receivethe reports and ensure continuous super-vision.

The inventory is a sort of a descriptionof the mandator’s assets at the time whenthe mandatary responsible for adminis-tering the property commences theirduties. An inventory is absolutely neces-sary if a verification of the mandatary’smanagement is required at a later date. Itshould include an accurate list anddescription of all the property to be man-aged, except for property and personaleffects worth less than $100, which canbe described generally (e.g., a set of 10dresses, 5 suits, kitchen utensils, an enve-lope of documents and pictures, etc.).

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The report concerning your protectionand the administration of your propertymay be made to a person close to you oranyone able to assess your mandatary’smanagement and take steps to improveit, if needed. Ideally, the person to whomthe mandatary reports regarding hismanagement will assist in making theinventory of the mandator’s property thatthe mandatary should make when com-mencing his duties.

4 RESPONSIBILITIES OF THE MANDATARY CONCERNING THE PROTECTION OF MY PERSON

These clauses are not obligatory: you cancross out some or all of the section youdo not want included in your mandate.

Remember that the mandatary to the per-son must be a physical person—a familymember, friend or someone else—whoserole will be to ensure the protection ofyour person and your moral and materialwelfare and to consent to certain care onyour behalf. If you do not authorize yourmandatary to give consent to care (4.3),consent will be given by your spouse oranother family member or friend.

5 RESPONSIBILITIES OF THE MANDATARY CONCERNING THE ADMINISTRATION OF MY PROPERTY

It is important to be clear about the powersyou give your mandatary.

By giving him the powers of simple admin-istration, your mandatary will requireauthorizations to perform certain significantactions. He will have to manage your day-to-day business and preserve and maintainyour moveable and immoveable property.He will not be able to sell assets withoutyour authorization if you are able to give it,and if not, without the authorization of thecourt, unless it involves assets that are per-ishable or likely to depreciate rapidly. If hemakes investments in your name, they mustbe "presumed sound," which means theymust comply with the definition given bythe Civil Code of Québec (several types ofbonds, certificates of deposit, etc.). 16


The mandatary who is given the powersof full administration has greater flexi-bility. In addition to preserving the assetsof the mandatary, if possible, he mustensure that they grow and increase invalue. He may also borrow or take out amortgage in your name, or even sell yourproperty without prior authorization.

The mandatary’s administration ends whenthe mandate is revoked or the mandatordies. As appropriate, the mandatary mustreport on his overall management to themandator who has regained his capacity,the heirs of the deceased mandator or themandatary or the legal representative(tutor or curator) who replaces him in hisduties.

6 ACCESS TO RECORDS

This clause is not obligatory. You cancross it out.

7 REMUNERATION

The provisions of the Civil Code of Québecstipulate that anyone who administersproperty for someone else is entitled to bereimbursed for expenses incurred in theexecution of their duties. They also statethat in principle, the execution of the man-date is done free of charge unless themandator wants to offer remuneration tothe mandatary.

You can therefore make provisions forthe mandatary responsible for takingcare of your person and/or the oneresponsible for managing your propertyto receive remuneration. Remunerationcan be calculated at an hourly rate forthe hours spent on your care or adminis-tration, in addition to reimbursement fortheir expenses. It is also possible for theremuneration of the mandatary to prop-erty to be calculated based on a percent-age of the value of the assets under man-agement. Obviously, if you designate atrust company or other legal entity, theapplicable management fees will bebilled to your assets.

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8 PARTIAL INCAPACITY

These clauses are not obligatory: youcan choose one of the two options bychecking the one that you want includedin your mandate or simply cross themout if none is applicable.

If none of the options is checked off, thecourt can refuse to homologate the mandate.

9 OTHER CLAUSES

These clauses are not obligatory: you cancross out some or all of the section youdo not want included in your mandate.

10 SIGNATURE OF THE MANDATOR AND DECLARATION OF WITNESSES

Mandators must inform the witnesses ofthe nature of the documents being sub-mitted to them but they do not have todisclose their contents.

The role of the witnesses is two-fold andvery important. By signing in the manda-tor’s presence, they attest that the docu-ment has been signed by the manda-tor or according to the mandator’sinstructions and that the mandator wascapable of doing so. This attestation maybe provided in an affidavit (declarationunder oath) of one of the witnesses. Thisaffidavit may be used as evidence whenthe mandate is being homologated.

In some cases, a witness may find it dif-ficult to judge the mandator’s capacity toprepare his mandate. If there are doubtsabout whether he is in full possession ofhis faculties, the mandatary appointed inthe document should, before signing,consult specialists in the health networkso that the mandator receives a conclu-sive assessment.

A witness may be deemed to "have aninterest" in the mandate if he is designatedmandatary or the substitute mandatary orif he is the one to whom the mandatarymust report. A witness may also be aperson specified in clause 9 on page 7 of 8.

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11 ACCEPTANCE BY THE MANDATARY

When the incapacity occurs, designatedmandataries are responsible for havingthe mandate homologated, and in doingso, their acceptance of the office isassumed. However, should they refuse orbe incapacitated, the substitute, if any,may act in their place.

It is recommended that you give a copyof the mandate to the designated man-datary or at least inform this person thata mandate has been prepared and whereit can be found.

You can also obtain the person’s immedi-ate acceptance and commitment to rep-resent you after you become incapable.

Please note that for mandates preparedby notaries or attorneys that are listed inthe Registre des dispositions testamen-taires et des mandats du Québec, friendsor family can perform searches to locateany registered mandate.

THE CURATEUR PUBLIC MUST BE NOTIFIED

• Upon the death of the mandator, themandatary informs the Curateur publicdu Québec.

• Upon the death of the mandatary, theliquidator of the succession reports thedeath to the Curateur public duQuébec.

REMINDER

If you need more space for any section ofthe form, you can add pages by number-ing them so that they refer to the appro-priate section.

PLEASE INITIAL THE MARGIN WHENEVER YOU

CHANGE A PRINTED TEXT.

NOTE

The text of the law always takes prece-dence over the information in this booklet.

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Contact the Curateur public du Québec

By phone

Monday to Friday8:30 a.m. to 4:30 p.m. (Wednesdays open at 10:00 a.m.) 514 873-4074 1 800 363-9020

By e-mail

www.curateur.gouv.qc.caContact us page of our website

By regular mailLe Curateur public du Québec600, boulevard René Lévesque OuestMontréal (Québec) H3B 4W9

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In the same collection

My Will

Cohabitation Contract

Application for the Probate of a Will

Joint Application for the Determinationof Custody Access and Child Support

Joint Application for Review of Accessory Measures

Joint Application for Divorceon Draft Agreement

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Printing completedin January 2010 by J.B. Deschamps inc.

in Québec

1 of 8

Initiales du mandant et des témoins (continuer au ver)

FormMy Mandate in Case of Incapacity

PLEASE PRINTWherever required by the context, any word written in the singular form also includes the plural, and any word written in the masculineform also includes the feminine.

IMPORTANTPlease read the explanatory notes on pages 14 through 19 of the booklet carefully. Eachsection of the form has a corresponding explanatory note.

If you would like to designate ONLY ONE MANDATARY to care for your person and administer yourproperty, fill out section 1, then go directly to section 3.

If you would like to designate SEVERAL MANDATARIES to care for your person and administer yourproperty together or one to care for your person and the other to administer your property, fill outsection 2, then go to section 3.

Please note that the administrator of your property can be someone in your family, a friend or some-one else you trust, or even a company, such as a trust company or other institution authorized bylaw to act in this capacity.

If you need more space for any section of the form, you can add pages by numbering them so thatthey refer to the appropriate section.

Please initial the margin whenever you change a printed text.

1 SINGLE MANDATARY (See note 1)

This mandate cancels all previous mandates in case of incapacity and, once homologated, it terminates anypower of attorney I have granted for the administration of my property.

I, the undersigned, , born on

hereby designate

to act as mandatary responsible for protecting my person and administering my property.

Indicate your relationship to this person:

1.1 Substitute mandatary

If my mandatary is unable to act for whatever reason,

I designate

to act as substitute mandatary.


NAME OF MANDATOR DAY MONTH YEAR

NAME OF MANDATARY

ADDRESS

ADDRESS

Initials of the mandator and witnesses (Continued on back)

NAME OF MANDATARY

2 of 8

2 MULTIPLE MANDATARIES (See note 2)

This mandate cancels all previous mandates in case of incapacity and, once homologated, it terminates anypower of attorney I have granted for the administration of my property.

I, the undersigned, , born on

hereby designate

to act as mandatary responsible for protecting my person.


I also designate

and (where relevant)

to act as mandatary responsible for the administration of my property.


When several mandataries act jointly, decisions must be made:

o unanimously OR o by majority

2.1 Substitute mandataries

If my mandatary is unable to act for whatever reason,

I also designate

to act as substitute mandatary responsible for protecting my person.


I also designate

to act as substitute mandatary responsible for administering my property.


Check if desired:

o In case of the resignation, death or legal incapacity of any of my mandataries mentioned above, theremaining mandatary will act as if he alone had been designated.


NAME OF MANDATOR DAY MONTH YEAR

NAME OF MANDATARY

ADDRESS

NAME OF SUBSTITUTE

ADDRESS

NAME OF MANDATARY

ADDRESS

NAME OF MANDATARY

ADDRESS

NAME OF SUBSTITUTE

ADDRESS

3 of 8

3 INVENTORY AND REPORT (See note 3)

3.1 Inventory

At the beginning of his functions, the mandatary responsible for the administration of my property shouldcomplete a summary inventory of all my moveable and immoveable property. This procedure must be per-formed in the presence of two witnesses, ideally including the person for whom the management reportwill be prepared, as appropriate.

3.2 Report

o My mandatary OR o Only his substitute OR o My mandatary and his substitute

must prepare an annual report of the actions taken with respect to my person and the administration ofmy property and submit it to

or, failing that person, to

4 RESPONSIBILITIES OF THE MANDATARY CONCERNING THE PROTECTION OF MY PERSON(See note 4)

4.1 General

My mandatary is responsible for ensuring my moral and material welfare. In this sense, he is authorized tomake any decisions and take any steps to meet my daily needs while respecting my wishes, my personaland religious values, my habits, my standard of living and degree of autonomy.

Wherever I live, my mandatary must ensure that I receive the care and services required by my health status.

As a general rule, I would like my mandatary to be "actively" present to the extent possible (regular visits,moral support, etc.).

4.2 Housing

If possible, I would like to live at home. However, if my health requires me to live in a setting that is saferand better adapted to my needs, my mandatary will decide according to the circumstances, while takinginto account the following wishes:


NAME

ADDRESS

NAME

ADDRESS

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4.3 Consent to care

If I am unable to consent to the care required by my health status or to refuse it, my mandatary shall doso on my behalf. In this respect, he shall act in my interest alone and take into account the wishes I haveexpressed to the extent possible and as provided by law. Should he be asked to consent to care, he shalluse all means necessary to make a well-informed decision, as discussed with the attending physician andhealthcare team. If he consents to the care suggested, it is with the conviction that it will be beneficial,despite its effects, appropriate in the context and the risks involved do not seem disproportionate giventhe beneficial effect targeted.

o Yes

OR

o No: I would like to consent to this care.

Indicate your relationship to this person: o

4.4 Clinical trials

I authorize my mandatary, if he feels that it is appropriate and complies with the applicable provisions ofthe Civil Code of Québec, to allow my participation in a research project or trial.

o Yes OR o No

4.5 Last wishes

In all decisions concerning care required at the end of my life, my mandatary must consider:

Check the desired options:

o my opposition to any disproportionate diagnostic method or therapy that needlessly worsens orprolongs my suffering and death;

o my wish to die with dignity, with the required supportive care and comfort and proper medication torelieve my suffering, even though it may indirectly accelerate my death;

o other details or wishes:

NAME OF PERSON

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NAME OF MANDATARY TO THE PERSON

NAME OF MANDATARY TO THE PROPERTY

NAME OF MANDATARY TO THE PROPERTY


NAME OF MANDATARY

NAME OF MANDATARY TO THE PERSON

5 RESPONSIBILITIES OF THE MANDATARY CONCERNINGTHE ADMINISTRATION OF MY PROPERTY (See note 5)

I grant my mandatary the power to administer my moveable and immoveable property according to therules of

o simple administration in accordance with the Civil Code of Québec

OR

o full administration in accordance with the Civil Code of Québec.


o I would not like the following moveable and immoveable property to be sold, unless necessary:

o I specifically authorize my mandatary to property

to act in my place as liquidator of a succession if these duties should be given to me.

6 ACCESS TO RECORDS (See note 6)

In the exercise of his functions, it is understood, as provided by law, that my mandatary is authorized toconsult my medical, personal and other records concerning my person and my property that may be use-ful to him.

7 REMUNERATION (See note 7)

My mandatary may reimburse himself out of my assets for all expenses that are helpful or necessary toexecute his duties, including fees for the homologation of the mandate.

o My mandatary or his substitute will act free of charge.

OR

o I would like

OR

o I would like

OR

o I would like

ANDns à ce

to be remunerated from my assets according to the following terms and conditions:

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8 PARTIAL INCAPACITY (See note 8)

If my incapacity is only partial:

o I require this mandate to be homologated with all powers specified in it.

I am fully aware that should I become partially incapable, some of the powers specified in this mandatecould limit my rights and my autonomy. Nevertheless, I want this mandate to be homologated.

I consider myself the person in the best position to know my interests. I believe that my mandatary willact fully to respect my rights and protect my autonomy, even if he holds the powers of fulladministration.

OR

o I prefer that my residual capacity be taken into account in my mandate.

If I am only unable to manage my property, the mandate concerning the administration of my propertymust be homologated.

My mandatary will then act with powers of o simple administration OR o full administrationand I will retain full autonomy in decisions about my person.

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9 VARIOUS CLAUSES (See note 9)


o I would like my mandatary to use a portion of the revenues from my assets, and even some capital ifnecessary, in order to assume my financial obligations to my family in the same manner that I have assumedthem until the homologation of this mandate. However, if these revenues have decreased considerably as aresult of my incapacity, my mandatary will assume these obligations to the extent of my means.

o For any decision concerning my person or the administration of my property, I want to be consulted, ifpossible, so that I can give my opinion. If my mandatary deems it appropriate, he will consult the mostsignificant persons among my friends and family, who are:

However, it is understood that my mandatary is entitled to make the final decision.

o If, at the time of the homologation of this mandate, one or more of my children are minors and must berepresented, I appoint:

to act as tutor.

o The mandatary to my person must have a new medical and psychosocial assessment conducted everyfive (5) years after the homologation of this mandate in order to reassess my condition. After receivingthese assessments, this person must make all decisions and take all necessary steps to protect my rightsand ensure that my autonomy is respected.

o If I regain my capacity again, my mandatary shall cease to represent me and begin procedures toterminate this mandate, unless I indicate otherwise.

10 SIGNATURE OF THE MANDATOR AND DECLARATION OF THE WITNESSES (See note 10)

10.1 Declaration of witnesses

We, the undersigned, and

have both witnessed the signature of .

We also declare that this person was fully capable of preparing this mandate and that we have no personalinterest in it.

In witness whereof, we have signed at this

NAME NAME

DAY MONTH YEARPLACE

NAME OF WITNESS

FULL ADDRESS

TELEPHONE NO.

NAME OF WITNESS

FULL ADDRESS

TELEPHONE NO.

NAME NAME

NAME NAME

NAME

NAME OF MANDATOR


SIGNATURE OF WITNESS SIGNATURE OF WITNESS

SIGNATURE OF THE MANDATOR

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11 ACCEPTANCE BY THE MANDATARY (See note 11)

o The request to homologate this mandate by my mandatary will be deemed his acceptance of this office.

OR

o The mandatary hereby designated in this mandate:

declares the following:

1. I acknowledge that I have read this mandate and agree

to be appointed mandatary to the property or to the person or to both.

2. I agree, in case of the incapacity of , to take the

measures required by law to homologate this mandate in case of incapacity and thereafter assume the

powers and obligations of my office as mandatary.

3. If at such a time I cannot assume the office of mandatary, the substitute mandatary shall carry on in my place.

4. I agree to fulfill my duties in the interest of

and to ensure the protection of this person's rights and autonomy.

THE CURATEUR PUBLIC MUST BE NOTIFIED

• Upon the death of the mandator, the mandatary informs the Curateur public du Québec.• Upon the death of the mandatary, the liquidator of the succession reports the death

to the Curateur public du Québec.

Please initial the margin whenever you change a printed text.

Initials of the mandator and witnesses

NAME OF MANDATARY

FULL ADDRESS

OCCUPATION

NAME OF MANDATOR

NAME OF MANDATOR

SIGNATURE OF ACCEPTING MANDATARY

My mandate in case of incapacityis for all adults who are of soundmind. It allows them to appoint a man-datary to ensure the protection of theirperson and the administration of theirproperty in the event that illness or anaccident deprives them of theirfaculties. It contains essentialinformation on the choice of man-datary, the various clauses thatmay be included in the mandateand its homologation.

This new edition features a com -pletely revised form, designed tooffer mandators a greater rangeof elements contributing to theirprotection.

Printed in Québec, Canada

$ 9.95

ISBN 978-2-551-19846-7

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