The High Court - Insolvency Service



|Name: Case Number: (Provided by Office) |

|Index |

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|Part A - Statement of Personal Information (Internal Office Document) |

|1.0 |Personal Details |

|2.0 |Employment & Income Assessment |

|3.0 |Members of Household and Dependants |

|4.0 |Assets |

|5.0 |Action by Sheriff / Creditors |

|6.0 |Business Details – Sole Trader / Partnership |

|7.0 |Details of Interest in Limited Companies |

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|Part B - Reasons leading to Bankruptcy |

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|Part C - Declaration |

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|Part D – Statistical Information |

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How to complete this form.

• Please use blue / black ball point pen if completing this form manually.

• Please use BLOCK LETTERS and place an X in the relevant boxes.

• Please answer all questions that apply to you. If a question does not apply to you, please enter N/A.

If you own a business please complete Part 6.

If you are involved in a limited company please complete Part 7.

If you need any help to complete this form, please contact Bankruptcy Division, Insolvency Service of Ireland, Block 2, Phoenix House, Conyngham Road, Dublin 8. Tel: (+353) 076 106 4200 or Email: bankruptcy@.ie

Part A - Statement of Personal Information

Basic Details - Please complete all fields

|Title: Mr □ Mrs □ Ms □ Other ____________ |First Name (s) |

|Surname |Any other names you are known by: (such as maiden name, alias or nickname) |

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|Home address: Owner □ Tenant □ |Have you resided at any other addresses in for past 10 years: |

| |Yes □ No □, If Yes Please list all previous addresses |

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|Date of birth: |Personal Public Service number: (PPS) |

|Home Telephone No |Mobile Telephone No |

|Daytime Telephone No |Email Address: |

|I am currently: Employed □ Self Employed □ |I am currently Unemployed □ |

|Marital Status: | | | |

| |□ Single |□ Co-habiting |□ A civil partner |

| |□ Married |□ Separated |□ A former civil partner |

| |□ Divorced |□ Widowed |□ A surviving civil partner |

|Are you, or in the last 5 years have you been, involved in proceedings|If Yes, please give details including any agreed settlement whether formal or |

|for divorce, separation or the dissolution of a civil partnership : |informal, and any gifts or transfers of property that occurred in those |

|Yes □ No □ |proceedings: |

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|If Yes, Provide name, address and reference of your solicitor in the | |

|proceedings: | |

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If Separated/divorced you must attach copies to the Office of your Separation Agreement and Divorce.

|Drivers licence number |Passport number: (copy required) |

Proof of Identity – Please supply a scanned copy of your Passport or Drivers Licence Photo Page.

|Have you been bankrupt before? Yes □ No □ |Have you previously entered, or have you tried to enter, into any formal |

| |arrangement (Debt Settlement or Personal Insolvency) with your creditors? |

|If Yes, please state date of adjudication of bankruptcy |Yes □ No □ |

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|__/__/____ |If Yes, give the name and address of the insolvency practitioner involved |

| |and the date of the arrangement: |

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|Are you involved in any legal proceedings? |If Yes, please give brief details of the nature of the proceedings, the name|

| |and address of any solicitor acting for you, the name of the relevant court |

|Yes □ No □ |and any case or reference number: |

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Employment Details

|If you are currently unemployed |

|When did you last work: |- -/ - -/- - - - |

|Who was your last employer: | |

|What was your employer’s address: | |

|What was your job title: | |

|If you are currently employed. |

|What is your job: | |

|Who is your employer: | |

|What is your employer’s address: | |

|When did you start this job: |- - / - - /- - - - |

|Weekly Net Income € | |

|What is the address of your local tax office? |

Income Assessment

The Official Assignee will as part of the Bankruptcy process assess your income against Reasonable Living Expenses (RLE). An Income Payment Agreement is calculated by subtracting your monthly RLE from your monthly income. Your RLE are calculated by adding the set costs based on your particular household composition to the other costs incurred by you for housing, childcare and special circumstances where they arise. Special circumstances include such costs as those related to ill-health/disability etc. This will enable us to assess how much you can afford to pay as part of an Income Payment Agreement for the benefit of your creditors. Details of RLE are available on our website at - .ie/en/ISI/Pages/RLE_calculated

|Monthly Income After Tax |€ |Supporting Documents Required when Submitting this form |Attached |

| | | |Tick All that |

| | | |Apply |

|Wages & Salaries | |Last Three Payslips. | |

|Work Related Expenses | |Receipts of Actual Expenditure for last 3 months | |

|Social Welfare Payment | |Department of Social Protection Last 3 Receipts. | |

|Rent Supplement / Allowance | |Department of Social Protection Last 3 Receipts. | |

|Private Pension | |Last 3 Statements from Pension Provider | |

|Maintenance Income | |3 Months Bank Statements showing Money Received. | |

|Total | | | |

|Are Department of Social Protection payments your only source of Income |

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|Yes □ |

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|If you ticked yes, please skip to page 5. N.B. Please ensure you provide your Department of Social Protection Receipts. |

Please state the % of household income earned by you

It is assumed that all Reasonable Living Expenses are incurred in proportion to income e.g. if you are earning 50% of household income you will be entitled to 50% of the expenditure. A claim for 100% assumes the bankrupt is the sole earner in the household.

Household Composition

|Please complete only one household composition type, indicate whether a car is needed and include the number of children residing at your home. |

|Household Composition |

|Number of Adults |1 |1 |1 |1 |2 |

|Infant 0 to 2 Years | | | | |

|Childcare | | |Copy of Agreement with Childcare Provider & Proof of last three | |

| | | |payments made. | |

|Actual Mortgage Costs | | |Bank Statements showing last three payments made. | |

|Actual Rent Costs | | |Lease Agreement & Bank Statements showing last 3 payments | |

| | | | | |

|Special Circumstances | | |Proof of Actual Payments made for Special Circumstances (Over last 3 | |

| | | |months) | |

|eg: Disability | | |Proof of Actual Payments made for Special Circumstances (Over last 3 | |

| | | |months) | |

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|Total | | | | |

Attachment of Earnings Order

|Do you have any current attachment of earnings orders in force against you? | |

|(e.g. Revenue / Family Law) |Yes □ No □ |

| | |

| |If yes, please provide a copy of the Attachment Order. |

Members of your Household & Dependants

Give the names and date of birth of all occupants of your household and state which, if any, are dependent on you.

|Name |Date of Birth |Relationship to you |Reason for dependency |

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|Apart from members of your household, is any other person dependent upon you? |Yes □ No □ |

If yes, provide details including their name, address and reason for dependency

|Name |Address |Reason for dependency |

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Assets

Property: If you have more than one property you are required to complete Appendix 1 for each additional property. Please use your Statement of Affairs (SOA) that you provided to the Court for your Bankruptcy in order to cross reference to the sheet below.

|Property Details |

|Property Description & Address: e.g. (3 Bed Semi | |

|Detached House at , 123 Narrow Road, D.6) | |

|Property Status : Family Home □ Second Home □ Investment Property □ Land □ |

|Is the property held in trust: | Yes □ No □ |

|Property reference on the SOA: | |

|(i.e. LB1) | |

|What is the value per SOA: |€ |

|What is the value of all moveable household |€ |

|contents | |

|What is your interest in the property: | Joint □ Sole □ Other __________ |

|% Property Ownership: | |

|(if jointly owned) | |

|Name(s) of joint owners: | |

|Address of joint owners: | |

|(if different from the property address) | |

|Type of security: |Mortgage □ Judgement Mortgage □ Both □ Other ____________ |

|Folio number: | |Mortgage provider: | |

|LPT Property ID: | | | |

|Mortgage account number: | |Mortgage account balance: |€ |

|Are you currently making mortgage monthly |Yes □ No □ |If yes, indicate type of payment: |Interest Only(€) □ Interest |

|repayments: | | |and Capital (€) □ |

|Current monthly repayments: |€ |Location of the title deeds: | |

|Is the property occupied |Yes □ No □ |If occupied who resides there: |You □ Other □ |

| | |If other, provide details: |

|Is the property rented: |Yes □ No □ | |

|Please provide the following details | |

|Tenant(s) Name(s): |Monthly rent: € |

| |Rent due date: ___/___/______ |

|Phone number: |E-mail address: |

|PRTB form number: | |

|Lease dates: |From: ___/___ /______ To: ___/___ /_____ |

|Name and address of letting/estate agent: (if applicable) |Name and address of management company: (if applicable) |

|Is the property currently insured: |Yes □ No □ |

|Date of last insurance policy: |___/___/_______ |

|Name of insurance company: | |

|Does the property have a BER cert: |Yes □ No □ |

|Property tax status: |Paid up to date □ In arrears □ |

|Commercial rates status: (if applicable) |Paid up to date □ In arrears □ |

|Water rates status: (if applicable) |Paid up to date □ In arrears □ |

Assets disposed of in the last Five Years

|Give details of any assets that you have sold, given away or transferred in the five years before the presentation of your bankruptcy petition. |

|Description of asset / investment | |

|What is your interest in the property: | Joint □ Sole □ Other __________ |

|% Property Ownership: | |

|(if jointly owned) | |

|Name(s) of joint owners: | |

|Address of joint owners: | |

|(if different from the property address) | |

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|To whom did you sell, transfer or give away the | |

|asset? | |

|Net sale proceeds (less any charges and legal fees) |€ |

|Details of solicitor (name and address) who acted on| |

|your behalf in the transaction | |

Assets Transferred in the last 12 Months

|Please detail all payments of money over €5,000, transfers of property to any creditor, or any charges created by you on property in favour of a |

|creditor, in the 12 month period prior to your adjudication as a bankrupt. |

|Date |Nature of Payment / Transfer / Charge |Recipient |Value |

| | | |€ |

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| | | |€ |

| | | |€ |

Investments

|Have you been a beneficiary of a trust in the last five years: |Yes □ No □ |

|Have you transferred any assets to a trust in the last five years: |Yes □ No □ |

|If Yes please provide a copy of the trust with this form |

|Have you received any payout from investment fund in past five years: |Yes □ No □ |

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|Date Received: | |

|Amount Received: |€ |

|Have you made a lump sum payment to any fund in past five years: |Yes □ No □ |

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|Date Paid: | |

|Amount Paid: |€ |

|Do you expect to receive payment from any investment in the next three years:|Yes □ No □ |

|Do you expect to receive a Tax Refund: (Please give details) |Yes □ No □ |

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|Year ended: | |

|Amount Expected: |€ |

Motor Vehicles

PLEASE ATTACH A PHOTOCOPY OF THE LOG BOOK/VEHICLE REGISTRATION CERTIFICATE. PLEASE COMPLETE ALL FIELDS ON CAR DESCRIPTION.

|Make/Model of Vehicle | |Name of finance company: | |

|Year & Engine Size i.e. 2006 1.4L | |Reference number of agreement: | |

|Vehicle Registration: | |Finance outstanding: |€ |

|Estimated value: |€ |Number of Doors & Saloon Type (i.e. 5| |

| | |door saloon) | |

|What is the Odometer reading (Total |KM |Fuel Type | |

|“Mileage” in KM) | | | |

|Insurance expiry date: | |Location of vehicle | |

|Transmission Type (Automatic or | |Name of any joint owner | |

|Manual) | | | |

|Does the vehicle have a valid NCT: If| |Give your general view on the | |

|yes, provide expiry date of NCT: | |condition of the vehicle | |

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|Do you have the use of a motor vehicle that you do not own: |Yes □ No □ |

|If yes, please give details below: | |

|Registration number | | |

|Owner | |

|Estimated value € | |

|If you have disposed of any vehicle in the last 12 months, please specify | |

|where the vehicle is now: | |

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Excepted Articles

Under section 45 (1) of the Bankruptcy Act 1988 an individual declared bankrupt shall be entitled to retain, as excepted articles, such articles of clothing, household furniture, bedding, tools or equipment of his trade or occupation or other necessaries for himself, his wife, children and dependent relatives residing with him, as he may select, not exceeding in value €6,000 or such further amount as the Court on an application by the bankrupt may allow.

Can you please provide details below of the items you want to declare as your excepted articles:

|Description of item |Value |Location |

| |€ | |

| |€ | |

| |€ | |

|Total |€ | |

Action by the Sherriff

|Has a sheriff’s officer visited you in the last 6 months: | |

| |Yes □ No □ |

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|If yes, date of visit: |___/___/_________ |

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|(A sheriff’s officer is an officer of the Court who may attend to remove assets for sale, if, for example,| |

|a judgment debt has not been paid) | |

|If Yes, please provide the following details: |

|Name of creditor |Amount of claim |Date of seizure |Description and estimated value of property seized |

| |€ | | |

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Contact Details for Creditors

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|In order to contact Creditors we require email addresses (essential) and postal addresses for any creditor that is NOT a Financial Institution, Utility |

|Company or a Government Body. |

|Reference on |Name of Creditor |Postal Address |Email Address |Relationship to you |

|Statement of | | | |(family member, |

|Affairs (UC1, | | | |friend, customer, |

|UC2 etc) | | | |etc) |

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Business Details – Sole Trader / Partnership

|Please complete this section if you are or have been self-employed (including a partner in a partnership) at any time in the last 12 months. If there |

|was more than one business you are required to complete a separate sheet for each. |

|Business Name: | |

|Business trading address: | |

|Was the business registered for VAT: |Yes □ No □ |

|If Yes, give the VAT number: | |

|If the business was a partnership give the name(s) and address(es) | |

|of the partner(s): | |

|Trading start date: | |

| Trading end date: (if applicable) | |

|At what address are your books of account and other accounting | |

|records kept: | |

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|What is the name and address of your accountant: | |

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|What is the name and address of your solicitor: | |

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|Have you employed anybody during the last four years: |Yes □ No □ |

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|If Yes, do you owe them any money, e.g. for wages, holiday pay or |Yes □ No □ |

|redundancy pay: | |

|Can any former employee claim that you owe them any money, e.g. for |Yes □ No □ |

|wages, holiday pay or redundancy pay? | |

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Please attach financial statements (balance sheet and income statement) for the last 3 years to this form.

Details of interest in Limited Companies

|Please complete this section if you had any interest in a limited company at any time in the last 5 years. |

|If you were involved in more than one limited company you are required to complete a separate sheet for each. |

|Are you or were you at any time in the last 5 years, a director of a limited|Yes □ No □ |

|company, or involved in its management: | |

|Company name: | |

|Company number: | |

|Shareholding: (%) | |

|Names and address and shareholding of other company directors and company | |

|secretaries: | |

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|Have you formally resigned as director: |Yes □ No □ |

|(under section 183 of the Companies Act a director must resign once | |

|adjudicated bankrupt) | |

|Has the company been formally dissolved: |Yes □ No □ |

|If yes, give details: |

|What was the company’s business: | |

|Company trading start date: ___/___/________ |Company trading end date: ___/___/________ (if applicable) |

|Has a liquidator, receiver or administrator been appointed to manage the |Yes □ No □ |

|company: | |

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|If Yes, please provide name & address: | |

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|Is a dividend distribution expected: (please give details) | |

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|Do you or have you at any time during last five years owned any shares in |Yes □ No □ |

|the company: |If Yes, please give details below: |

|No of shares |Percentage Shareholding % |Date Sold |Transferee Name and Address |Sale Proceeds |

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|Have you transferred any assets to the company in the last five years: |Yes □ No □ |

| |If Yes, please give details below: |

|Description of Asset |Date of transfer |Value of Asset |Monies Received |

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|Who prepares the financial statements and tax returns for company: |

|Phone No.: |Address: |

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|Email: | |

Please attach financial statements (balance sheet and income statement) for the last 3 years to this form.

Part B - Reasons leading to Bankruptcy

What do you think are the reasons for you not having enough money to pay your debts:

Tick one cause only that best describes the main cause of your financial difficulties.

|Non Business Related |Business Related |

|Unemployment of loss of Income |□ |Economic conditions affecting industry |□ |

|Adverse legal action |□ |Lack of business ability |□ |

|Liabilities due to guarantees |□ |Excessive interest payments on loans |□ |

|Gambling, speculation |□ |Excessive drawings |□ |

|Ill Health |□ |Failure to provide for taxation |□ |

|Excessive use of credit facilities |□ |Lack of sufficient initial working capital |□ |

| | |Gambling or speculation |□ |

|When did you first have difficulty paying your debts? Month Year |

Part C - Declaration

I hereby confirm that my answers to all the above questions (including any extra information on pages following this declaration) are to the best of my knowledge and belief true and accurate as at today’s date. I understand that I will likely be committing a criminal offence if I deliberately give false information in relation to my bankruptcy.

You may type your signature into the document.

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|Your signature: |

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|Name: _____________________ |

|BLOCK CAPITALS |

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|Date: |

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Part D – Statistical Information

QUESTIONNAIRE

Please answer questions by ticking relevant box

|1. Gender | |7. Mortgage debt | |

| Male |□ |Less than €200,000 |□ |

| Female |□ |€200,000 to €600,000 |□ |

| | |Over €600,000 |□ |

|2. Bankruptcy Type | | | |

| Self adjudication |□ |8. Nature of debts: | |

| Petition by creditor |□ |Consumer |□ |

| | |Business |□ |

|3. Petitioning Creditor | |Business and Consumer |□ |

|Bank |□ | | |

|Credit Union |□ |9. Insolvency: Business or Non-Business (i.e. is | |

| | |insolvency related to any proprietary interest in a | |

| | |business) | |

|Financial Institution |□ | | |

|Company |□ |Business Insolvency |□ |

|Revenue |□ |Non-Business |□ |

|Individual |□ |No business |□ |

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|4. Value of Petition debt | |10. Business Debt | |

|Less than €50,000 |□ |Less than €50,000 |□ |

|€50,000 to €200,000 |□ |€50,000 to €200,000 |□ |

|€200,000 to €600,000 |□ |€200,000 to €600,000 |□ |

|Over €600,000 |□ |Over €600,000 |□ |

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|5. Occupation: | |11. Personal Debt | |

|Businessperson |□ |Less than €50,000 |□ |

|Profession |□ |€50,000 to €200,000 |□ |

|Trade |□ |€200,000 to €600,000 |□ |

|Other |□ |Over €600,000 |□ |

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|6. Debts other than mortgage debt | |12. Employment Status | |

|Less than €50,000 |□ |Currently Employed |□ |

|€50,000 to €200,000 |□ |Unemployed |□ |

|€200,000 to €600,000 |□ |Self Employed |□ |

|Over €600,000 |□ | | |

Checklist

Have you filled in using black / blue ball point pen if completing manually, BLOCK LETTERS and placed an X in the relevant boxes.

Have you answered all questions that apply to you?

Have you completed Part 6 if you owned a business in the last 12 months?

Have you completed Part 7 if you have been involved in a limited company in the past 5 years.

SUPPORTING DOCUMENTS - The following documents should be provided with this form:

• A scanned copy of your passport or drivers licence (photo page)

• Provide copies of any settlement agreements (divorce or separation) which took place in previous 5 years.

• All income should be supported by documents such as pay slips, bank statements, social welfare receipts and any other relevant documentation. We will only contact your employer in exceptional circumstances to confirm your income details. Following our review of your income we may request further back-up documentation if necessary.

• If you are self employed please provide us with a copy of your most recent financial statements.

• You must provide proof of each item listed in expenditure. For example, for childcare costs – please provide receipts. For Mortgage – please provide bank statements showing monies paid in the last 3 months and for Rent a lease agreement where rent is paid by you should be provided.

• Special Circumstances may only be claimed if you provide receipts and proof that these special circumstances are real costs incurred by you. Please note that the ISI will review any request for Special Circumstances but may decide not to allow for such costs.

• Please provide a copy of any Attachment Order attached to your income.

• You must provide the following supporting documentation in relation to your properties;

o Copy of all leases where the property is rented

o Copy of all property insurance policies

o BER Certificates for properties

o Copy of rates bills where applicable

• You must provide a photocopy of your Vehicle’s Vehicle Registration Certificate as proof of ownership and to allow us obtain an independent valuation.

• Please provide a copy of any Trust you have including any supporting documentation.

• Please provide financial statements (balance sheet and income statement) for the last 3 years if you have a business.

• Please provide financial statements (balance sheet and income statement) for the last 3 years if you have been involved in a limited company in the last 5 years.

Appendix 1 (Blank Property Page – Complete for each property)

Please use your Statement of Affairs (SOA) that you provided to the Court for your Bankruptcy in order to cross reference to the sheet below.

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|Property Details |

|Property Address: | |

| |

|Property Status : Family Home □ Second Home □ Investment Property □ Land □ |

|Is the property held in trust: | Yes □ No □ |

|Property reference on the SOA: | |

|(i.e. LB1) | |

|What is the value per SOA: |€ |

|What is the value of all moveable household |€ |

|contents | |

|What is your interest in the property: | Joint □ Sole □ Other __________ |

|% Property Ownership: | |

|(if jointly owned) | |

|Name(s) of joint owners: | |

|Address of joint owners: | |

|(if different from the property address) | |

|Type of security: |Mortgage □ Judgement Mortgage □ Both □ Other ____________ |

|Folio number: | |Mortgage provider: | |

|LPT Property ID: | | | |

|Mortgage account number: | |Mortgage account balance: |€ |

|Are you currently making mortgage monthly |Yes □ No □ |If yes, indicate type of payment: |Interest Only(€) □ Interest |

|repayments: | | |and Capital (€) □ |

|Current monthly repayments: |€ |Location of the title deeds: | |

|Is the property occupied |Yes □ No □ |If occupied who resides there: |You □ Other □ |

| | |If other, provide details: |

|Is the property rented: |Yes □ No □ | |

|Please provide the following details | |

|Tenant(s) Name(s): |Monthly rent: € |

| |Rent due date: ___/___/______ |

|Phone number: |E-mail address: |

|PRTB form number: | |

|Lease dates: |From: ___/___ /______ To: ___/___ /_____ |

|Name and address of letting/estate agent: (if applicable) |Name and address of management company: (if applicable) |

|Is the property currently insured: |Yes □ No □ |

|Date of last insurance policy: |___/___/_______ |

|Name of insurance company: | |

|Does the property have a BER cert: |Yes □ No □ |

|Property tax status: |Paid up to date □ In arrears □ |

|Commercial rates status: (if applicable) |Paid up to date □ In arrears □ |

|Water rates status: (if applicable) |Paid up to date □ In arrears □ |

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Statement of Personal Information(SPI)

2016

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