FORM 55
AN CHÚIRT CHUARDA
THE CIRCUIT COURT
O.41A r. 1
CIRCUIT COUNTY OF
........... Prosecutor
........... Accused
No. ........
Fines (payment and recovery) act 2014, section 7(4)
Statement of financial circumstances
Please note:
1. Please complete this Statement of Financial Circumstances carefully and accurately. If you need assistance in completing this Statement of Means, you may wish to contact your solicitor (if you have one), the Money Advice and Budgeting Service or a Citizens Information Centre.
2. If you knowingly or recklessly make a statement in your financial statement that is false or misleading in any material respect, you shall be guilty of an offence and shall be liable upon summary conviction to a Class B fine, being a fine not exceeding €4,000 or imprisonment for a term not exceeding 6 months or both.
3. If you are in receipt of any social welfare payments it is most important in your own interests that you bring with you your social services card and produce it to the Court.
4. If any of your details do not fit in the space provided, please attach a separate sheet giving those details.
5. You are advised to keep a copy of this Statement of Means and bring it with you to Court.
To the Circuit Court office at .....
As required by the notice served on me in the above-named proceedings, I now lodge the following statement of my financial circumstances.
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1. Income: Please set out in this section each means by which your income is earned (e.g. employment) or the source of your income (e.g. social welfare benefits) and the annual amount you receive from each means or source. |
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2. Property (real and personal): Please give in this section a description of any assets which you own (e.g. money in bank, car etc) and the approximate value of each showing, where relevant, the gross value and the net value if the property is subject to any loan, etc). If you have no relevant assets, strike through this section. |
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3. Liabilities Please give in this section a description of any liabilities you have which you are currently repaying and the approximate value of each. |
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Please include details of your outgoings (e.g. rent, household expenses, gas/electricity, loan repayments) and the annual amount you pay for each. |
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Please also include in this section if you are at present making payments on foot of any other court orders (e.g. instalment orders, maintenance etc). If you are, please give details of the amounts and the reference numbers and bring with you to court copies of any relevant documents. |
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Please provide details in this section of other people who you are legally or morally liable to support, for example your children or any relative who relies on you. If there is no relevant person, strike through this section. |
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Name: |
Address: |
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4. Money owed to you Please give details of all monies owing to you, the dates upon which they fall due to be paid and the likelihood of their being paid. |
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5. Personal public service number (PPSN) Please state your personal public service number (PPSN) |
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6. Employment details |
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Please state the name and address of your employer |
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Please provide your employee number, payroll number or equivalent, if applicable |
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I say that, to the best of my knowledge and belief, the particulars given above and on any attached sheet are accurate and true.
Dated this ...... day of ...... 20...
Signed :............ fined person
of .........
Form 55 inserted by SI 379 of 2018, effective 17 October 2018.