Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697804280470.pdf (Ireland)
STATUTORY INSTRUMENTS.

S.I.

No.

215 of 2022 ________________ PERSONAL INSOLVENCY ACT 2012 (PRESCRIBED DEBT RELIEF NOTICE APPLICATION FORM) REGULATIONS 2022 2 [215] S.I.

No.

215 of 2022 PERSONAL INSOLVENCY ACT 2012 (PRESCRIBED DEBT RELIEF NOTICE APPLICATION FORM) REGULATIONS 2022 The Insolvency Service of Ireland, in exercise of the powers conferred on it by section 3 of the Personal Insolvency Act 2012 (No.

44 of 2012), hereby makes the following regulations: 1.
These Regulations may be cited as the Personal Insolvency Act 2012 (Prescribed Debt Relief Notice Application Form) Regulations 2022.

2.

The form set out in the Schedule to these Regulations is hereby prescribed for the purposes of section 29(2) of the Personal Insolvency Act 2012 (No.

44 of 2012).

3.

The Personal Insolvency Act 2012 (Prescribed Debt Relief Notice Application Form) Regulations 2013 (S.I.

No.
No.

333 of 2013) and the Personal Insolvency Act 2012 (Prescribed Debt Relief Notice Application Form) (Amendment) Regulations 2022 (S.I.

No.

18 of 2022) are hereby revoked.

Notice of the making of this Statutory Instrument was published in “Iris Oifigiúil” of 3rd May, 2022.

[215] 3 Schedule ISI Case Reference No.

: APPLICATION FOR DEBT RELIEF NOTICE AN CHÚIRT CHUARDA THE CIRCUIT COURT […………] CIRCUIT COUNTY OF [……….]
IN THE MATTER OF AN APPLICATION UNDER SECTION 31 OF THE PERSONAL INSOLVENCY ACT 2012 AND IN THE MATTER OF [………………………………….]

OF [……………………………………………………..], A DEBTOR I ………………………………………………………… of ………………………………………………………………….
County of ………………………………………………………… HEREBY APPLY for the making of an order for the issue under section 31(2)(a) of the Personal Insolvency Act 2012 of a Debt Relief Notice in respect of the debts specified in the application under section 29 of the said Act which the Court is satisfied are qualifying debts.

Dated ………….20….. 4 [215] ISI Case Reference No.

: Important Information and Statements 1.


Unless otherwise defined in this application form, terms used herein have the same meaning as under the Personal Insolvency Act 2012 (the “Act”).

2.

This application form has been prescribed by the Insolvency Service for the purposes of Section 29(2) of the Act.

3.
3.

The Insolvency Service may request any further information it requires from an approved intermediary and defer further consideration of the application until such information is furnished to the Insolvency Service.

Failure to furnish such information, within 14 days or such longer period as the Insolvency Service may (at its discretion) permit, will mean that the application shall be deemed to have been withdrawn.

4.
4.

Where a debtor (the “Debtor”) becomes aware of any inaccuracy or omission in this application or any document accompanying this application, or any material change in his or her circumstances between the date of the application and the date on which the application is reviewed by the appropriate court, he or she is required under section 29(3) of the Act to inform the approved intermediary of these facts as soon as practicable.
An approved intermediary who receives such information is required under section 29(4) of the Act to furnish that information to the Insolvency Service without delay.

5.

The Insolvency Service shall process the Debtor’s personal data in accordance with its Privacy Notice which is available on its website, www.isi.gov.ie.

6.
6.

The Insolvency Service hereby agrees to the Debtor communicating with the Insolvency Service by electronic means for the purposes of any communication or notice required or permitted to be sent or given by the Debtor to the Insolvency Service, from time to time, in connection with this Act including for the purpose of any notice referred to in section 134 of the Act.

Any such communication or notice should be sent to drn@isi.gov.ie.

7.
7.

Notwithstanding any agreement by the Debtor to receiving electronic communications and notices, there may be circumstances in which the Insolvency Service will send documents, information and other communications to the Debtor in hard copy rather than electronically, in which case the Insolvency Service reserves the right to do so, including for the purpose of giving the Debtor any notice referred to in section 134 of the Act.

8.
8.

This application may be withdrawn at any time prior to the issue of a Debt Relief Notice in accordance with section 29(5) of the Act.

9.

This application shall be accompanied by the prescribed fee and the following documentation - (a) a copy of the statement made by the approved intermediary under section 27(6) of the Act; (b) the Debtor’s signed confirmation that he or she satisfies the eligibility criteria specified in section 26(2) of the Act; ISI Case Reference No.
: [215] 5 (c) the Prescribed Financial Statement completed under section 27 of the Act and a statutory declaration of the Debtor confirming that the statement is a complete and accurate statement of the Debtor’s assets, liabilities, income and expenditure; (d) a schedule of the creditors of the Debtor and the debts concerned, stating in relation to each such creditor the information specified in section 29(2)(d) of the Act; (e) (f) (g) the Debtor’s written consent to the disclosure and processing of his or her personal data as specified in section 29(2)(e) of the Act; the Debtor’s written consent to the making of any enquiry under section 30 of the Act relating to the Debtor by the Insolvency Service; the Debtor’s signed statement stating whether, to the best of his or her knowledge, there is any judgment or court order in force against him or her which relates to a debt which is a qualifying debt; (h) such other documentation as may be requested in this application.
6 [215] Application Form ISI Case Reference No.

: DEBTOR’S DETAILS – Initial Information Yes □ No □ Yes □ No □ Yes □ No □ Has the Debtor confirmed in writing to the approved intermediary that he or she wishes to apply for a Debt Relief Notice?

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.

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.

DEBTOR’S DETAILS – Personal Details Surname: First name: Name as certificate: it appears on birth [215] 7 ISI Case Reference No.

: Is the Debtor or has the Debtor been known by any other name?
Yes □ No □ Name(s): Mr Mrs Miss Ms Other (please specify) Male Female Other If yes, please supply name(s): Title:* Gender:* 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 Civil partnership divorce/annulment) Separated Divorced Widow/Widower Current Address: Home telephone number : Mobile telephone number: Email address: 8 [215] ISI Case Reference No.
: DEBTOR’S DETAILS – Previous Addresses Has the Debtor had any previous addresses in the last 5 years?

Yes □ No □ If yes, please supply address(es): Address(es): Start date and end date: DEBTOR’S DETAILS – Employment Status is What employment status?
* the Debtor’s current 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: [215] 9 ISI Case Reference No.
: 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?

Yes □ No □ If not, what is the percentage of the Debtor’s ownership of the business?

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 the Employment Status section, under a trading/business name or any other name other than the Debtor’s current name?
Yes □ No □ Name(s) and Address(es): If yes, please supply all previous name(s) and address(es) Start date and end date: DEBTOR DETAILS – Insolvency Status Is the Debtor, as a debtor, as of the date of this application, a party to a Debt Settlement Arrangement or a Personal Insolvency Arrangement which is in effect?

Yes □ No □ 10 [215] Is the Debtor as of the date of this application a discharged bankrupt to a bankruptcy payment subject order?
Is the Debtor, as a debtor, as of the date of this application, subject to an arrangement under the control of the court under Part IV of the Bankruptcy Act 1988?

ISI Case Reference No.

: Yes □ No □ Yes □ No □ DEBTOR DETAILS – Prior Insolvency Processes Has the Debtor ever been a specified debtor with respect to a Debt Relief Notice?

Has the Debtor applied for a protective certificate (under Chapter 3 or 4 of the Act) within the period of 12 months ending on the date of this application?
the Debtor successfully Has completed Settlement a Debt Arrangement or Personal Insolvency Arrangement within the period of 5 years ending on the date of this application?

Has the Debtor applied for bankruptcy and the petition has not been adjudicated before the date of this application?

If yes, does section 26(9) of the Act apply and if so, please provide details.

Yes □ No □ Yes □ No □ Yes □ No □ Yes □ No □ Yes □ No □ Details: [215] 11 ISI Case Reference No.
: Yes □ No □ Has a creditor of the Debtor before the date of this application petitioned to make the Debtor bankrupt but the hearing concerned has not yet taken place?

If yes, does section 26(10) of the Act apply and if so, please provide details.

Yes □ No □ Details: Has the Debtor, before the date of this application, been adjudged bankrupt and the adjudication has not been annulled or discharged?
Has the Debtor been discharged from bankruptcy within the period of 5 years ending on the date of this application?

Yes □ No □ Yes □ No □ 12 [215] ISI Case Reference No.

: DEBTOR DETAILS – Other Eligibility Criteria Does the Debtor have qualifying debts that amount to €35,000 or less?

Yes □ No □ Does the Debtor have a net disposable income, calculated in accordance with section 26(5) of the Act, of €60 or less a month?
Yes □ No □ assets, the Debtor have Does calculated in accordance with section 26(6) of the Act, worth €1,500 or less?

Yes □ No □ Is the Debtor domiciled in the State, or within one year before the date of this application, has the Debtor ordinarily- Yes □ No □ Domiciled Resided Business Yes □ No □ (i) (ii) resided in the State, or had a place of business in the State?
* Is the Debtor, taking into account the factors set out in section 26(7) of the Act, insolvent within the meaning of the Act and has no likelihood of becoming solvent within a period of 3 years from the date of this application, while also maintaining a reasonable standard of living for himself or herself and his or her dependants?

[215] 13 ISI Case Reference No.


: Yes □ No □ Yes □ No □ Yes □ No □ Has the Debtor, during the period of two years ending on the date of this application, entered into a transaction with a person at an undervalue that has materially contributed to the Debtor’s inability to pay his or her debts (other than any debts due to the person with whom the the Debtor transaction at an undervalue)?
entered Has the Debtor, during the period of two years ending on the date of this application, given a preference to a person that has had the effect of substantially reducing the amount available to the Debtor for the payment of his or her debts (other than a debt due to the person who received the preference)?

Has 25% or more of the Debtor’s qualifying debts been incurred during the period of 6 months ending on the date of this application?
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 Expenses Guidelines”), is this a one adult household or a two adult household?

* Living Does the Debtor have any dependent children (under 19 years of age) living with him or her?
If yes, complete – Reasonable Living Expenses – Children One adult household Two adult household Yes □ No □ 14 [215] ISI Case Reference No.

: Yes □ No □ Does the Debtor own a motor vehicle?

If yes, does the Debtor require a motor vehicle?

Yes □ No □ The monthly total set costs under the Reasonable Expenses Living Guidelines for the Debtor’s typical household are: Does the Debtor have any childcare costs?
Yes □ No □ If yes, please give the monthly expenditure amount assessed to be reasonable approved intermediary in accordance with the Reasonable Expenses Living Guidelines?

the by How much is the Debtor’s monthly rent, mortgage repayment or other accommodation costs assessed to be approved reasonable intermediary in accordance with the Reasonable Expenses Living Guidelines?
the by Monthly amount: € € Yes □ No □ 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 the Debtor In the case of a two adult household, the has presumption of an equal split of the reasonable living expenses between them?

rebutted Yes □ No □ [215] 15 ISI Case Reference No.
: Yes □ No □ Percentage: Yes □ No □ What percentage of the Debtor’s household reasonable living expenses should be attributed to the Debtor?

Does the Debtor have any expenditure in relation to Home Insurance and/or Motor Insurance, which is required to be account when calculating his or her reasonable living expenses?
taken into If yes, complete – Reasonable Living Expenses – Home and Motor Vehicle Insurances The Debtor’s expenses are:- reasonable living € 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 this amount expenditure.

details and of Amount: € Comments: REASONABLE LIVING EXPENSES – Home and Motor Vehicle Insurances Please give the monthly expenditure amount this expenditure.

details and of Amount: € Comments: 16 [215] JURISDICTION With reference to section 5(2) of the Act, please specify relevant County of the Debtor?
Circuit Court: Reason for specifying County:* ISI Case Reference No.
: Debtor residing at the time of this application Debtor resided within one year of the time of this application Debtor has a place of business at the time of this application Debtor had a place of business within one year of the time of this 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.

[215] 17 GIVEN under the seal of the Insolvency Service of Ireland, 29 April, 2022.

MICHAEL MCNAUGHTON, Director of the Insolvency Service of Ireland.
18 [215] EXPLANATORY NOTE (This note is not part of the Instrument and does not purport to be a legal interpretation) These Regulations prescribe the form to be used when making an application to the Insolvency Service of Ireland for a Debt Relief Notice.

These Regulations also revoke the Personal Insolvency Act 2012 (Prescribed Debt Relief Notice Application Form) Regulations 2013 (S.I.

No.
No.

333 of 2013) and the Personal Insolvency Act 2012 (Prescribed Debt Relief Notice Application Form) (Amendment) Regulations 2022 (S.I.

No.

18 of 2022).
No.

18 of 2022).

[215] 19 BAILE ÁTHA CLIATH ARNA FHOILSIÚ AG OIFIG AN tSOLÁTHAIR Le ceannach díreach ó FOILSEACHÁIN RIALTAIS, BÓTHAR BHAILE UÍ BHEOLÁIN, CILL MHAIGHNEANN, BAILE ÁTHA CLIATH 8, D08 XAO6 Teil: 046 942 3100 r-phost: publications@opw.ie —————— DUBLIN PUBLISHED BY THE STATIONERY OFFICE To be purchased from GOVERNMENT PUBLICATIONS, MOUNTSHANNON ROAD, KILMAINHAM, DUBLIN 8, D08 XAO6 Tel: 046 942 3100 E-mail: publications@opw.ie —————— €4.50 (ISI-5) 75.

5/22.

Propylon.