Application to authorise a deprivation of liberty (Sections 4A(3) and 16(2)(a) of the Mental Capacity Act 2005)
| Published date | 21 March 2018 |
1
For office use only
Date received
Case no.
Date issued
COP
DOL11
12.17
Court of Protection
SEAL
Application to authorise
a deprivation of liberty
(Sections 4A(3) and 16(2)(a) of the
Before completing this form please read the guidance at page 28 - General
Information for completing form. You can download forms and leaflets at
hmctsformfinder.justice.gov.uk. Search for form type: ‘Court of Protection’.
Please give the full name of P (the person the application is about)
1. Is this application urgent?
No, go to question 2
Yes, and my reasons for urgency are below
Give any factors that ought to be brought specifically to the court’s attention (the applicant being under a
specific duty to make full and frank disclosure to the court of all facts and matters that might have an impact
upon the court’s decision).
A streamlined procedure pursuant to Re X and Ors (Deprivation
of Liberty) [2014] EWCOP 25 and Re X and Ors (Deprivation of
Liberty)(Number 2) [2014] EWCOP 37
Payment
How is the application fee being paid?
Cheque
Payment by Account - please give your PBA number
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2
Mr. Mrs. Miss Ms. Other
Full name
Post held/Job
title
Name of
organisation
Address
DX number
Telephone
Email
3. Your details (the applicant)
2. Order sought
Please specify the nature of the order you seek and attach a draft.
Duration of the Order sought
If granted the deprivation of liberty will be reviewed by
the court at least annually. Do you consider that the
authorisation will require a shorter review period?
Yes No
If Yes, please provide details
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