of ................

*(in court area and district aforesaid)

WHEREAS a summons was issued under

*section 11 (2) of the Petty Sessions (Ireland) Act, 1851]

*section 1 of the Courts (No. 3) Act, 1986]

in a case of summary jurisdiction entitled

........... *Complainant *Prosecutor

-v-

............ *Defendant *Accused

and said summons was for hearing at a sitting of the Court for the above-named court area on the ... day of ..... 19 ...,

AND WHEREAS the applicant herein is the *defendant *accused named in the summons,

AND WHEREAS the Court on the .... day of ..... 19..., proceeded to hear the *complaint *accusation to which the summons related,

AND WHEREAS the applicant herein, being the person to whom the summons was directed, did not receive notice of the summons or of the hearing to which the summons related until the ... day of .... 19..., being a time after the commencement of the said hearing,

TAKE NOTICE THAT I, the said applicant, intend to apply to the District Court for the said court area, within the time specified in section 22 (6) (a) of the Courts Act, 1991, upon the date and at the time to be fixed by you, to have the said proceedings set aside.

My address within the State for the service of documents *is as shown above/ *is ...................

Dated this .... day of ....... 19 .... .

Signed ...................

Applicant

To the District Court Clerk for the said court area,

at the District Court Office,

........................

* Delete words inapplicable