S.I. No. 331/2013 - Personal Insolvency Act 2012 (Prescribed Protective Certificate Personal Insolvency Arrangement Application Form) Regulations 2013.

APPLICATION QUESTIONS

Is this an individual application or a joint application?If this is a joint application each Debtor must complete the “Debtor’s Details” sections.

Individual Joint

If an individual application, is it proposed that this application will be administered in common with one or more other Personal Insolvency Arrangements pursuant to Section 89 (4) of the Personal Insolvency Act 2012 ? If yes, provide ISI case reference number(s) for the relevant arrangement(s).

Yes No Case Reference No(s).:

Are the total liabilities of the Debtor as determined on the basis of the Prescribed Financial Statement completed by the Debtor in respect of this application in excess of €2,500,000?

Yes No

Has 25% or more of the Debtor’s debts (other than excluded debts) been incurred during the period of 6 months ending on the date of this application?

Yes No

Is the aggregate of the debts of the Debtor which are secured debts less than €3,000,000?

Yes No

If no, have all of the creditors who are secured creditors consented in writing so that the limit of €3,000,000 shall not apply?If yes, please provide a copy of the consent with this application.

Yes No

Is at least one of the creditors of the Debtor a secured creditor holding security over an interest in property (real or personal) of the Debtor situate in the State?

Yes No

DEBTOR’S DETAILS — Initial Information

Has the Debtor received advice from the personal insolvency practitioner on the matters set out in section 52 of the Act?

Yes No

Was the advice referred to in section 52(1)(c) of the Act confirmed in writing by the personal insolvency practitioner to the Debtor?

Yes No

Has the Debtor instructed the personal insolvency practitioner in writing to make a proposal for a Personal Insolvency Arrangement in accordance with Chapter 4 of the Act?

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 above, 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 an undischarged bankrupt?

Yes No

Is the Debtor a discharged bankrupt subject to a bankruptcy payment order?

Yes No

Is the Debtor a person who is a specified debtor as respects a Debt Relief Notice which is in effect?

Yes No

Is the Debtor a person who, as a debtor, is subject to a Debt Settlement Arrangement which is in effect?

Yes No

Is the Debtor a person who, as a debtor, is 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 been the subject of a protective certificate issued under section 95 of the Act less than 12 months prior to the date of this application?

Yes No

Has the Debtor had his or her debts discharged pursuant to a final Debt Relief Notice less than 3 years prior to the date of this application?

Yes No

Has the Debtor had his or her debts discharged pursuant to a Debt Settlement Arrangement less than 5 years prior to the date of this application?

Yes No

Has the Debtor been discharged from bankruptcy less than 5 years prior to the date of this application?

Yes No

Has the appropriate court made an order referred to in section 91(3) of the Act stating that it is satisfied that the current insolvency of the Debtor arises by reason of exceptional circumstances or other factors which are substantially outside the control of the Debtor and that it would be just to permit the Debtor to make a proposal for a Personal Insolvency Arrangement? If yes, please provide a copy of the order with this application. Only to be answered if any of the previous four questions are answered in the positive.

Yes No

Has the Debtor ever entered into a Personal Insolvency Arrangement?

Yes No

DEBTOR’S DETAILS — Other Eligibility Criteria

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 insolvent within the meaning of the Act?

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 household Two 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 personal insolvency practitioner 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 personal insolvency practitioner 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:

JURISDICTIONOnly applicable if Circuit Court Application

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 ofbusiness 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.