Financial Guardian Suitability Assessment Form

1. Applicant Details

Name Relationship to Vulnerable Adult Address Contact Number Email

2. Details of Vulnerable Adult

Name Date of Birth Reason for Vulnerability Current Living Arrangements

3. Suitability Assessment

Why do you believe you are suitable to act as a Financial Guardian? Have you previously managed finances for anyone else? Yes No If yes, please provide details Do you have any criminal convictions? Yes No If yes, please provide details Are you currently or have you ever been bankrupt or subject to insolvency proceedings? Yes No If yes, please provide details References (Names and Contact Information)

4. Declaration

I declare that the information provided above is, to the best of my knowledge, true and complete. Name Date Signature