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FORM 34A

 

AN CHÚIRT CHUARDA
THE CIRCUIT COURT

           CIRCUIT                                                                                                         COUNTY OF
 

IN THE MATTER OF THE GRAND JURY (IRELAND) ACT, 1836 AND IN THE MATTER OF ................, APPLICANT


 

 

NOTICE OF PRELIMINARY APPLICATION FOR COMPENSATION FOR CRIMINAL INJURY TO THE PERSON

 

To: The County Secretary/Town Clerk of [insert name of Local Authority] …………………...
 

And
To: The Member in Charge of ............... Garda Síochána Station
 

YOU AND EACH OF YOU ARE HEREBY REQUESTED TO TAKE NOTICE that on the ...... day of .......... at ……............. in the County of , .................., Applicant, of .................. in the County of ...................., ...................... being a witness against ............................charged with an offence against the public peace


OR
.......................……….……………….............. a Magistrate/Peace Officer (delete as appropriate)
was maliciously maimed/murdered and that it is intended to apply to the Circuit Court for compensation for the said injury/death pursuant to the provisions of Section 106 of the Grand Jury (Ireland) Act, 1836, as amended.
 

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

Signed ...………............... 
Applicant/Solicitor for the Applicant/Person on behalf of the Applicant