Common use of Responsible Party Clause in Contracts

Responsible Party. Signature: ............................................................................................. Name: ................................................................................................. Date: .................................................................................................. Signature: ............................................................................................. Signed for and on behalf of: ........................................................................... Name: ................................................................................................. Position: General Manager / Deputy General Manager / Regional Director Date: .................................................................................................. Name Date of Birth National Insurance Number Date of Occupation Type of Care Residential Care Nursing Care Type of Residency Permanent Respite Neighbourhood Residential Memory Care Room details Days / Night Departure Date Respite Fee Service Fee (comprising a daily fee of £ x 7 Days) £ Nursing Service Fee, if any (comprising a daily fee of £ x 7 Days) £ Total Weekly Fee including nursing fee (comprising a daily fee of £ x 7 Days) £ Care Level Your Payment £ Funding Authority Payment £ Responsible Party Payment £ Third Party Payment £ Name Address Contact Telephone Number The Services to be provided under the terms of this Agreement include the following:

Responsible Party. Signature: ............................................................................................. Name: ................................................................................................. Date: .................................................................................................. Signature: ............................................................................................. Signed for and on behalf of: ........................................................................... Name: ................................................................................................. Position: General Manager / Deputy General Manager / Regional Director Date: .................................................................................................. Name Date of Birth National Insurance Number Date of Occupation Type of Care Residential Care Nursing Care Type of Residency Permanent Respite Neighbourhood Residential Memory Care Room details Days / Night Departure Date Respite Fee Service Total Weekly Fee (comprising a daily fee of £ x 7 Days) £ Nursing Service Fee, if any (comprising a daily fee of £ x 7 Days) £ Total Weekly Fee including nursing fee (comprising a daily fee of £ x 7 Days) £ Care Level Your Payment £ Funding Authority Payment £ Responsible Party Payment £ Third Party Payment £ Name Address Contact Telephone Number The Services to be provided under the terms of this Agreement include the following:Number

Responsible Party. Signature: ............................................................................................. ................................................................................... Name: ................................................................................................. .. ............................................ ........................................ Date: .................................................................................................. . .. .. .................................................................................. Signature: ............................................................................................. ................................................................................... Signed for and on behalf of: ........................................................................... of Name: ................................................................................................. ...................................................................................... Position: h General Manager / h Deputy General Manager / h Regional Director Date: .................................................................................................. ....................................................................................... Schedule 1 Name Date of Birth National Insurance Number Date of Occupation Type of Care h Residential Care h Nursing Care Type of Residency h Permanent h Respite Neighbourhood Household h Residential h Memory Care Room details Days / Days/Night Departure Date Respite Fee Service Total Weekly Fee (comprising a daily fee of £ x 7 Days) £ Nursing Service Fee, if any (comprising a daily fee of £ x 7 Days) £ Total Weekly Fee including nursing fee (comprising a daily fee of £ x 7 Days) £ Care Level Complete if applicable Your Payment £ Funding Authority Payment £ Responsible Party Payment £ Third Party Payment £ Name Address Contact Telephone Number The Services to be provided under the terms of this Agreement include the following:Schedule 2