S.I. No. 333/2013 - Personal Insolvency Act 2012 (Prescribed Debt Relief Notice Application Form) Regulations 2013.

DEBTOR’S DETAILS — Initial Information

Has the Debtor confirmed in writing to the approved intermediary that he or she wishes to apply for a Debt Relief Notice?

Yes No

Does the Debtor agree to receiving by electronic means communications or notices required or permitted to be sent or given to the Debtor by the Insolvency Service, from time to time, in connection with the Act or related rules of court?

Electronic communications or notices will be sent to the Debtor’s email address provided in this application form.

Yes No

The Courts Service may wish to communicate with the Debtor, from time to time, by electronic means in connection with the Act or related rules of court. If such circumstances arise, does the Debtor agree to receiving by electronic means communications or notices required or permitted to be sent or given to the Debtor by the Courts Service in connection with the Act or related rules of court?

Electronic communications or notices will be sent to the Debtor’s email address and/or mobile telephone number provided in this application form.

Yes No

DEBTOR’S DETAILS — Personal Details

Surname:

First name:

Name as it appears on birth certificate:

Is the Debtor or has the Debtor been known by any other name?

If yes, please supply name(s):

Yes No Name(s):

Title:*

Mr

Mrs

Miss

Ms

Other (please specify)

Gender:*

Male

Female

Other

PPS number:

Date of birth:

Country of birth:

Nationality:

Current Marital Status:*

Single (never married)

Married (first marriage, no previous annulment)

Married (following previous annulment)

Re-married (following death of spouse)

Re-married (following divorce/annulment)

Civil partnership

Separated

Divorced

Widow/Widower

Current Address:

Home telephone number:

Mobile telephone number:

Email address:

DEBTOR’S DETAILS — Previous Addresses

Has the Debtor had any previous addresses in the last 5 years?

If yes, please supply address(es):

Yes No Address(es):

Start date and end date:

DEBTOR’S DETAILS — Employment Status

What is the Debtor’s current employment status?*

Employed

Self-employed/Trading

Unemployed

Retired

Student

Housewife/husband

Other (please specify)

If “Employed” is chosen the following questions must be answered:

Occupation:

Name of employer:

Address of employer:

Length of Service with employer:

Please specify in years and months.

If “Self-employed/Trading” is chosen the following questions must be answered:

Occupation:

Type of Business:

Trading/Business Name:

Address of Business:

Was/Is the business registered for VAT?

If yes, please supply VAT number.

Yes No VAT number:

Is the Debtor a sole trader?

If not, what is the percentage of the Debtor’s ownership of the business?

Yes No Percentage:

When did the business start trading?

Please specify a year and a month.

DEBTOR’S DETAILS — Previous Businesses

Has the Debtor ever carried on a business, other than that referred to in the Employment Status section, under a trading/business name or any other name other than the Debtor’s current name?If yes, please supply all previous name(s) and address(es).

Yes No Name(s) and Address(es):

Start date and end date:

DEBTOR’S DETAILS — Insolvency Status

Is the Debtor, as a debtor, as of the date of this application, a party to a Debt Settlement Arrangement or a Personal Insolvency Arrangement which is in effect?

Yes No

Is the Debtor as of the date of this application a discharged bankrupt subject to a bankruptcy payment order?

Yes No

Is the Debtor, as a debtor, as of the date of this application, subject to an arrangement under the control of the court under Part IV of the Bankruptcy Act 1988 ?

Yes No

DEBTOR’S DETAILS — Prior Insolvency Processes

Has the Debtor ever been a specified debtor with respect to a Debt Relief Notice?

Yes No

Has the Debtor applied for a protective certificate (under Chapter 3 or 4 of the Act) within the period of 12 months ending on the date of this application?

Yes No

Has the Debtor successfully completed a Debt Settlement Arrangement or a Personal Insolvency Arrangement within the period of 5 years ending on the date of this application?

Yes No

Has the Debtor applied for bankruptcy and the petition has not been adjudicated before the date of this application?If yes, does section 26(9) of the Act apply and if so, please provide details.

Yes No Yes No Details:

Has a creditor of the Debtor before the date of this application petitioned to make the Debtor bankrupt but the hearing concerned has not yet taken place?If yes, does section 26(10) of the Act apply and if so, please provide details.

Yes No Yes No Details:

Has the Debtor, before the date of this application, been adjudged bankrupt and the adjudication has not been annulled or discharged?

Yes No

Has the Debtor been discharged from bankruptcy within the period of 5 years ending on the date of this application?

Yes No

DEBTOR’S DETAILS — Other Eligibility Criteria

Does the Debtor have qualifying debts that amount to €20,000 or less?

Yes No

Does the Debtor have a net disposable income, calculated in accordance with section 26(5) of the Act, of €60 or less a month?

Yes No

Does the Debtor have assets, calculated in accordance with section 26(6) of the Act, worth €400 or less?

Yes No

Is the Debtor domiciled in the State, or within one year before the date of this application, has the Debtor ordinarily—

(i) resided in the State, or

(ii) had a place of business in the State?*

Yes No

Domiciled

Resided

Business

Is the Debtor, taking into account the factors set out in section 26(7) of the Act, insolvent within the meaning of the Act and has no likelihood of becoming solvent within a period of 3 years from the date of this application, while also maintaining a reasonable standard of living for himself or herself and his or her dependants?

Yes No

Has the Debtor, during the period of two years ending on the date of this application, entered into a transaction with a person at an undervalue that has materially contributed to the Debtor’s inability to pay his or her debts (other than any debts due to the person with whom the Debtor entered the transaction at an undervalue)?

Yes No

Has the Debtor, during the period of two years ending on the date of this application, given a preference to a person that has had the effect of substantially reducing the amount available to the Debtor for the payment of his or her debts (other than a debt due to the person who received the preference)?

Yes No

Has 25% or more of the Debtor’s qualifying debts been incurred during the period of 6 months ending on the date of this application?

Yes No

REASONABLE LIVING EXPENSES (RLE)

For the purposes of calculating the monthly total set costs under the guidelines on a reasonable standard of living and reasonable living expenses issued under Section 23 of the Act (the “Reasonable Living Expenses Guidelines”), is this a one adult household or a two adult household?*

One adult householdTwo adult household

Does the Debtor have any dependent children (under 19 years of age) living with him or her?

If yes, complete —Reasonable Living Expenses — Children.

Yes No

Does the Debtor own a motor vehicle?

Yes No

If yes, does the Debtor require a motor vehicle?

Yes No

The monthly total set costs under the Reasonable Living Expenses Guidelines for the Debtor’s typical household are:

€

Does the Debtor have any childcare costs? If yes, please give the monthly expenditure amount assessed to be reasonable by the approved intermediary in accordance with the Reasonable Living Expenses Guidelines.

Yes No Monthly amount: €

How much is the Debtor’s monthly rent, mortgage repayment or other accommodation costs assessed to be reasonable by the approved intermediary in accordance with the Reasonable Living Expenses Guidelines?

€

Does the Debtor have any expenditure in relation to special circumstances, which is required to be taken into account when calculating his or her reasonable living expenses?If yes, complete —Reasonable Living Expenses — Special Circumstances.

Yes No

In the case of a two adult household, has the Debtor rebutted the presumption of an equal split of the reasonable living expenses between them?

Yes No

What percentage of the Debtor’s household reasonable living expenses should be attributed to the Debtor?

Percentage:

The Debtor’s reasonable living expenses are:

€

REASONABLE LIVING EXPENSES — Children

For the purposes of calculating the Debtor’s reasonable living expenses under the Reasonable Living Expenses Guidelines, which of the following age categories does the Debtor’s child(ren) fall into?*

Infant (0-2) Pre-school (3) Primary school (4-11) Secondary school (12-18)

REASONABLE LIVING EXPENSES — Special Circumstances

Please give the monthly expenditure amount and details of this expenditure.

Monthly amount: €Details:

JURISDICTION

With reference to section 5(2) of the Act, please specify relevant County of the Debtor:

Circuit Court:

Reason for specifying County:*

Debtor residing at the time ofthis application

Debtor resided within one yearof the time of this application

Debtor has a place of business at the time of this application

Debtor had a place of businesswithin one year of the time ofthis application

Signature of Debtor:

______________

Printed Name of Debtor:

______________

Date:

______________

Note: This document will be completed in electronic format on such electronic platform that the Insolvency Service may from time to time make available or otherwise specify for such purpose, following which, the information will be processed into an output format which may be in electronic form or printed on paper. Where any item in this document is completed to the effect of ‘no’, or any item in this document is not completed, that information may not appear on such output format and any person reviewing the output format should proceed on the basis that, where the output format does not refer to such information, the relevant item was either completed by selecting ‘no’ or the relevant item was not applicable in that instance. In this document, where an asterisk (*) is used and a choice is provided of the appropriate response, the response selected will appear in the output format. This note will not appear on the output format.