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Notice of the making of this Statutory Instrument was published in
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“Iris Oifigiúil” of 13th May, 2022.
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The Insolvency Service of Ireland, in exercise of the powers conferred on it by
section 3
and
section 136
of the
Personal Insolvency Act 2012
(No. 44 of 2012), and with the consent of the Minister for Justice, hereby makes the following regulations:
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1. These Regulations may be cited as the Personal Insolvency Act 2012 (Prescribed Financial Statement) (Amendment) Regulations 2022.
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2. In these Regulations “Principal Regulations” means the Personal Insolvency Act 2012 (Prescribed Financial Statement) Regulations 2014 (S.I. No. 259 of 2014).
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3. The Principal Regulations are amended by substituting the form set out in Schedule 1 to these Regulations for the form set out in Schedule 1 to the Principal Regulations.
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4. The Principal Regulations are amended by substituting the form set out in Schedule 2 to these Regulations for the form set out in Schedule 2 to the Principal Regulations.
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SCHEDULE 1
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Case Ref No.:
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PRESCRIBED FINANCIAL STATEMENT
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Debt Relief Notice
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Name of Debtor:
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Address:
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Assets & Liabilities – Summary
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Total
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Assets
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€
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Principal Private Residence (PPR)
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Investments (real property)
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Investments (other than real property)
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Plant, Equipment, Tools
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Vehicles
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Stock in trade
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Money owed to you
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Bank/Building Society Accounts
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Credit Union (net asset)
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Cash on hand
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Prospective assets
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Contingent assets
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Other
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__________
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Total Assets
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__________
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Liabilities (debts)
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Qualifying debts
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Non-Qualifying debts
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Total
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€
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€
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€
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Principal Private Residence lender
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Financial Institutions
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Credit Union (net liability)
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Excludable Debts - Revenue
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Excludable Debts - Other than Revenue
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Employees
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Trade creditors
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Connected creditors
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Other debts
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Prospective debts
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Contingent debts
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Excluded debts
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Total debts
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__________
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__________
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Assets less Liabilities
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__________
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__________
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All assets/debts are stated net of offsets
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__________
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Income & Expenditure – Summary
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Income (monthly)
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€
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Salary/Wages - gross
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Pension income
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Income from self employment (before tax)
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Rental income (net of expenses)
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Income from Investments
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Contribution from household members
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Income from boarders/lodgers
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Income from State agencies
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Child or Spousal Maintenance
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Department of Social Protection
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Income - Other
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__________
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Total income
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__________
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Expenditure (monthly)
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€
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|
Income Tax / Social Insurance/Mandatory Pension
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Reasonable Living Expenses - set costs per guide
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Reasonable Living Expenses - rent/mortgage
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Reasonable Living Expenses – Motor Vehicle Insurance
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Reasonable Living Expenses – Home Insurance
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Reasonable Living Expenses - childcare costs
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Reasonable Living Expenses - special circumstances
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Payments in respect of Excluded Debts
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Payments in respect of Excludable Debts not permitted
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__________
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Total Monthly Expenditure
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__________
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__________
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Net disposable income
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__________
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Assets – Detail
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1
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Principal Private Residence
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1.1
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Address (note 1)
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1.2
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Current market value
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1.3
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Debtor ownership %
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1.4
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Debtor’s interest (derived field)
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1.5
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Comment
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2
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Investment Property
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2.1
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Description/Type*
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Description/Type*
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2.2
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Address (note 1)
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Residential buy to let - apartment
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2.3
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Current market value
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Residential buy to let - house
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2.4
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Debtor ownership %
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Commercial buy to let
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2.5
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Debtor’s interest (derived field)
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Commercial premises
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2.6
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Monthly income
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Holiday home
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2.7
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Monthly expenditure (excluding debt repayment)
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Land
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2.8
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Comment
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Other - provide details
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3
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Investments (other than real property)
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3.1
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Description/Type*
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Description/Type*
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3.2
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Name of security issuer
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Stocks/shares
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3.3
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Address (note 1)
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Bonds
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3.4
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Current market value
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Endowment policies
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3.5
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Debtor ownership %
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Pension
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3.6
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Debtor’s interest (derived field)
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Antiques
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3.7
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Monthly income
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Precious metals/Jewellery
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3.8
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Is the asset located in the State? Yes □ No □
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Prize Bonds
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3.9
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Comment
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Livestock
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Other - provide details
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4
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Plant, Equipment, Tools
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4.1
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Description
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4.2
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Current market value
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4.3
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Debtor ownership %
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4.4
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Debtor’s interest (derived field)
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4.5
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Is the asset located in the State? Yes □ No □
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4.6
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Comment
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5
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Vehicles
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5.1
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Make
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5.2
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Model
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5.3
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Year
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5.4
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Registration number
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5.5
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Kilometres
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5.6
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Need for vehicle
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5.7
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Current market value
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5.8
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Subject to finance? Yes □ No □
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5.9
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Balance outstanding
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5.10
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Monthly instalment
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5.11
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Adapted for disabled use? Yes □ No □
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5.12
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Is the asset located in the State? Yes □ No □
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5.13
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Comment
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6
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Stock in trade
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6.1
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Current market value
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6.2
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Is the asset located in the State? Yes □ No □
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6.3
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Comment
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7
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Money owed to you
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7.1
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Name of debtor
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7.2
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Address (note 1)
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7.3
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Book value
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7.4
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Realisable amount
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7.5
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Comment
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8
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Bank/Building Society Accounts
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8.1
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Name of bank/building society
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8.2
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Address (note 1)
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8.3
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Account name
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8.4
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Account number
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8.5
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Balance
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8.6
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Debtor ownership %
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8.7
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Debtor’s interest (derived field)
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8.8
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Comment
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9
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Credit Union Shares/Investment
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9.1
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Name of credit union
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9.2
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Address (note 1)
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9.3
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Account name
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9.4
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Account number
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9.5
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Current market value (less loan)
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9.6
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Debtor ownership %
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9.7
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Debtor’s interest (derived field)
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9.8
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Comment
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10
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Cash on hand
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10.1
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Amount
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10.2
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Is the asset located in the State? Yes □ No □
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10.3
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Comment
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11
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Prospective assets
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11.1
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Description
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11.2
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Estimated value
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11.3
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Estimated date of receipt
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11.4
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Is the asset located in the State? Yes □ No □
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11.5
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Comment
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12
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Contingent assets
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12.1
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Description
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12.2
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Estimated value
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12.3
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Estimated date of receipt
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12.4
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Is the asset located in the State? Yes □ No □
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12.5
|
Comment
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13
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Other
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13.1
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Description
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13.2
|
Estimated value
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13.3
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Is the asset located in the State? Yes □ No □
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13.4
|
Comment
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Liabilities – Detail
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Questions common across all debt headings (except excluded debts):
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1
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Is this debt secured? Yes □ No □
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If yes, security type:
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Mortgage/Charge
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Other - if other please give details
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What is the debt secured on?
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1
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Principal Private Residence Lender
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1.1
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Account Number
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1.2
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Account Name
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1.3
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Contact details (note 2)
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1.4
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Current monthly payment due
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1.5
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Monthly repayments - actual
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1.6
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Remaining term (months)
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1.7
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Amount due
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1.8
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Is the liability joint and several? Yes □ No □
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1.9
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If no, state % of liability
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1.10
|
Amount of debtor’s liability (derived field)
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1.11
|
Restructured? Yes □ No □ If yes please provide details
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1.12
|
Current interest rate
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1.13
|
Comment
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2
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|
Financial Institutions
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2.1
|
Account Number
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2.2
|
Account Name
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2.3
|
Contact details (note 2)
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2.4
|
Account Type*
|
Account Type*
|
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2.5
|
Current monthly payment due
|
Mortgage
|
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|
2.6
|
Monthly repayments - actual
|
Personal loan
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2.7
|
Purpose of loan
|
Overdraft
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|
2.8
|
Amount due
|
Credit card
|
|
|
2.9
|
Is the liability joint and several? Yes □ No □
|
Store card
|
|
|
2.10
|
If no, state % of liability
|
Other – provide details
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|
|
2.11
|
Amount of debtor’s liability (derived field)
|
|
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|
2.12
|
Restructured? Yes □ No □ If yes, please provide details
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2.13
|
Comment
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3
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|
Credit Union
|
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3.1
|
Account Number
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3.2
|
Account Name
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3.3
|
Contact details (note 2)
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3.4
|
Current monthly payment due
|
|
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3.5
|
Monthly repayments - actual
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|
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3.6
|
Purpose of loan
|
|
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|
3.7
|
Amount due (net liability)
|
|
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|
3.8
|
Is the liability joint and several? Yes □ No □
|
|
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|
3.9
|
If no, state % of liability
|
|
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|
3.10
|
Amount of debtor’s liability (derived field)
|
|
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|
3.11
|
Restructured? Yes □ No □ If yes, please provide details
|
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3.12
|
Comment
|
|
|
4
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|
Excludable Debts - Revenue
|
|
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|
4.1
|
Description/Type*
|
Description/Type*
|
|
|
4.2
|
Contact details (note 2)
|
Income Tax
|
|
|
4.3
|
Permitted? Yes □ No □
|
Vat
|
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|
4.4
|
If yes, creditor consent or deemed consent
|
PAYE/PRSI
|
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|
4.5
|
If creditor consents, please scan letter of consent
|
Relevant Contracts Tax
|
|
|
4.6
|
If deemed consent, scan letter requesting consent
|
Local Property Tax
|
|
|
4.7
|
Amount due
|
Interest & penalties
|
|
|
4.8
|
Preferential amount included in amount due (where known)
|
Other – provide details
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|
4.9
|
Instalment arrangement? Yes □ No □
|
|
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|
4.10
|
Amount of instalment
|
|
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|
4.11
|
Comment
|
|
|
5
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|
Excludable Debts - Other than Revenue
|
|
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|
5.1
|
Description/Type*
|
Description/Type*
|
|
|
5.2
|
Contact details (note 2)
|
Local Government (Charges) Act 2009
|
|
|
5.3
|
Permitted? Yes □ No □
|
Rates - Local Government Act 2001
|
|
|
5.4
|
If yes, creditor consent or deemed consent
|
HSE (Nursing Homes Support Scheme Act 2009)
|
|
|
5.5
|
If creditor consents, please scan letter of consent
|
Service charges/contributions under MUD Act 2011
|
|
|
5.6
|
If deemed consent, scan letter requesting consent
|
Social Welfare Consolidation Act 2005
|
|
|
5.7
|
Amount due
|
Other – provide details
|
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|
5.8
|
Preferential amount included in amount due (where known)
|
|
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|
5.9
|
Comment
|
|
|
6
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|
Employees
|
|
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|
6.1
|
Description/Type*
|
Description/Type*
|
|
|
6.2
|
Contact details (note 2)
|
Arrears of wages
|
|
|
6.3
|
Amount due
|
Minimum notice
|
|
|
6.4
|
Preferential amount included in amount due (where known)
|
Holiday pay
|
|
|
6.5
|
Comment
|
Redundancy
|
|
7
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|
Trade creditors
|
|
|
|
8.1
|
Contact details (note 2)
|
|
|
|
8.2
|
Amount due
|
|
|
|
8.3
|
Comment
|
|
|
8
|
|
Connected creditors
|
|
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|
9.1
|
Contact details (note 2)
|
|
|
|
9.2
|
Purpose of loan
|
|
|
|
9.3
|
Amount due
|
|
|
|
9.4
|
Please specify the connection
|
|
|
|
9.5
|
Comment
|
|
|
9
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|
Other debts
|
|
|
|
10.1
|
Description
|
|
|
|
10.2
|
Contact details (note 2)
|
|
|
|
10.3
|
Purpose of debt
|
|
|
|
10.4
|
Amount due
|
|
|
|
10.5
|
Comment
|
|
|
10
|
|
Prospective debts
|
|
|
|
11.1
|
Description
|
|
|
|
11.2
|
Contact details (note 2)
|
|
|
|
11.3
|
Amount due
|
|
|
|
11.4
|
Payment date
|
|
|
|
11.5
|
Comment
|
|
|
11
|
|
Contingent debts
|
|
|
|
12.1
|
Description
|
|
|
|
12.2
|
Contact details (note 2)
|
|
|
|
12.3
|
Estimated amount
|
|
|
|
12.4
|
Estimated payment date
|
|
|
|
12.5
|
Comment
|
|
|
12
|
|
Excluded debts
|
|
|
|
13.1
|
Amount due
|
|
|
|
13.2
|
Comment
|
|
|
| | |
Note 1
Address
Country
Street (line 1)
Street (line 2)
Street (line 3)
Town
Zip/Postal code
County
|
|
| | |
Note 2
Contact details:
Legal name of creditor
Country
Street (line 1)
Street (line 2)
Street (line 3)
Town
Zip/Postal code
County
Email Address
Telephone Number
|
|
| | |
Monthly Income – Detail
|
|
|
|
|
€
|
|
|
|
Type of income
|
Amount
|
|
1
|
|
Salary/Wages - gross
|
|
|
|
|
Comment
|
|
|
2
|
|
Pension income
|
|
|
|
|
Comment
|
|
|
3
|
|
Income from self employment (before tax)
|
|
|
|
|
Comment
|
|
|
4
|
|
Rental income (net of expenses)
|
|
|
|
|
Comment
|
|
|
5
|
|
Income from investments
|
|
|
|
|
Comment
|
|
|
6
|
|
Contribution from household members
|
|
|
|
|
Comment
|
|
|
7
|
|
Income from boarders/lodgers
|
|
|
|
|
Comment
|
|
|
8
|
|
Income from State agencies
|
|
|
|
|
Comment
|
|
|
9
|
|
Department of Social Protection
|
|
|
|
9.1
|
Jobseekers Allowance/Benefit
|
|
|
|
|
Comment
|
|
|
|
9.2
|
Disability Allowance
|
|
|
|
|
Comment
|
|
|
|
9.3
|
Carer’s Allowance
|
|
|
|
|
Comment
|
|
|
|
9.4
|
Family Income Supplement
|
|
|
|
|
Comment
|
|
|
|
9.5
|
Rent Supplement
|
|
|
|
|
Comment
|
|
|
|
9.6
|
One Parent Family Payment
|
|
|
|
|
Comment
|
|
|
|
9.7
|
Child Benefit
|
|
|
|
|
Comment
|
|
|
|
9.8
|
Mortgage Interest Supplement
|
|
|
|
|
Comment
|
|
|
|
9.9
|
Other –Please specify
|
|
|
|
|
Details
|
|
|
|
|
Comment
|
|
|
10
|
|
Child or Spousal Maintenance
|
|
|
|
|
Comment
|
|
|
11
|
|
Income - Other
|
|
|
|
|
Comment
|
|
|
|
|
Total monthly income
|
|
|
| | |
Monthly Expenditure – Detail
|
|
|
|
|
€
|
|
|
|
Type of expenditure
|
Amount
|
|
1
|
|
Income Tax / Social Insurance/Mandatory Pension
|
|
|
|
1.1
|
Income Tax
|
|
|
|
|
Comment
|
|
|
|
1.2
|
PRSI
|
|
|
|
|
Comment
|
|
|
|
1.3
|
Universal Social Charge
|
|
|
|
|
Comment
|
|
|
|
1.4
|
Mandatory Pension
|
|
|
|
|
Comment
|
|
|
|
1.5
|
Other - please specify
|
|
|
|
|
Details
|
|
|
|
|
Comment
|
|
|
2
|
|
Reasonable Living Expenses - set costs (derived)
|
|
|
3
|
|
Reasonable Living Expenses - rent/mortgage
|
|
|
4
|
|
Reasonable Living Expenses – motor vehicle insurance
|
|
|
5
|
|
Reasonable Living Expenses – home insurance
|
|
|
6
|
|
Reasonable Living Expenses - childcare costs
|
|
|
7
|
|
Reasonable Living Expenses -special circumstances
|
|
|
8
|
|
Payments in respect of Excluded Debts
|
|
|
9
|
|
Payments in respect of Excludable Debts not permitted
|
|
|
|
|
Total monthly expenditure
|
|
|
| |
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.
|
|
| |
SCHEDULE 2
|
| |
Case Ref No.:
|
| |
PRESCRIBED FINANCIAL STATEMENT
|
| |
Debt Settlement Arrangement/Personal Insolvency Arrangement
|
| |
Name of Debtor(s):
|
| |
Address:
|
| | |
Assets & Liabilities - Summary
|
|
|
|
|
Total
|
|
Assets
|
|
|
€
|
|
Principal Private Residence (PPR)
|
|
|
|
|
Investments (real property)
|
|
|
|
|
Investments (other than real property)
|
|
|
|
|
Plant, Equipment, Tools
|
|
|
|
|
Vehicles
|
|
|
|
|
Stock in trade
|
|
|
|
|
Money owed to you
|
|
|
|
|
Bank/Building Society Accounts
|
|
|
|
|
Credit Union (net asset)
|
|
|
|
|
Cash on hand
|
|
|
|
|
Prospective assets
|
|
|
|
|
Contingent assets
|
|
|
|
|
Other
|
|
|
__________
|
|
Total Assets
|
|
|
__________
|
|
Liabilities (debts)
|
Specified Debts
|
Unspecified Debts
|
Total
|
|
|
€
|
€
|
€
|
|
Principal Private Residence lender
|
|
|
|
|
Financial Institutions
|
|
|
|
|
Credit Union (net liability)
|
|
|
|
|
Excludable Debts - Revenue
|
|
|
|
|
Excludable Debts - Other than Revenue
|
|
|
|
|
Employees
|
|
|
|
|
Trade creditors
|
|
|
|
|
Connected creditors
|
|
|
|
|
Other debts
|
|
|
|
|
Prospective debts
|
|
|
|
|
Contingent debts
|
|
|
|
|
Excluded debts
|
|
|
|
|
Total debts
|
__________
|
__________
|
|
|
__________
|
__________
|
|
Assets Less Liabilities
|
|
|
__________
|
|
|
|
|
__________
|
|
| |
All assets/debts are stated net of offsets
|
| | |
Income & Expenditure - Summary
|
|
|
|
|
Total
|
|
Income (monthly)
|
|
|
€
|
|
Salary/Wages -gross
|
|
|
|
|
Pension income
|
|
|
|
|
Income from self employment (before tax)
|
|
|
|
|
Rental income (net of expenses)
|
|
|
|
|
Income from investments
|
|
|
|
|
Contribution from household members
|
|
|
|
|
Income from boarders/lodgers
|
|
|
|
|
Income from State agencies
|
|
|
|
|
Child or Spousal Maintenance
|
|
|
|
|
Other Income
|
|
|
|
|
Department of Social Protection
|
|
|
|
|
Total income
|
__________
|
|
|
|
|
__________
|
|
|
|
Expenditure (monthly)
|
|
|
|
|
Income Tax / Social
|
|
|
|
|
Insurance/Mandatory Pension
|
|
|
€
|
|
General Expenses
|
|
|
|
|
Rent
|
|
|
|
|
Total Monthly Expenditure before debt repayment
|
__________
|
|
|
|
|
__________
|
|
|
|
Net disposable income/available for debt service/arrears
|
__________
|
|
|
|
|
__________
|
|
|
|
|
Monthly Repayments-Actual
|
Current Monthly Payment Due
|
|
|
Payments in relation to debt repayments/arrears
|
€
|
€
|
|
|
| | |
Assets - Detail
|
|
1
|
|
Principal Private Residence
|
|
|
|
1.1
|
Address (note 1)
|
|
|
|
1.2
|
Current market value
|
|
|
|
1.3
|
Debtor ownership %
|
|
|
|
1.4
|
Debtor’s interest (derived field)
|
|
|
|
1.5
|
Comment
|
|
|
2
|
|
Investment Property
|
|
|
|
2.1
|
Description/Type*
|
Description/Type*
|
|
|
2.2
|
Address (note 1)
|
Residential buy to let - apartment
|
|
|
2.3
|
Current market value
|
Residential buy to let - house
|
|
|
2.4
|
Debtor ownership %
|
Commercial buy to let
|
|
|
2.5
|
Debtor’s interest (derived field)
|
Commercial premises
|
|
|
2.6
|
Monthly income
|
Holiday home
|
|
|
2.7
|
Monthly expenditure (excluding debt repayment)
|
Land
|
|
|
2.8
|
Comment
|
Other - provide details
|
|
3
|
|
Investments (other than real property)
|
|
|
|
3.1
|
Description/Type*
|
Description/Type*
|
|
|
3.2
|
Name of security issuer
|
Stocks/shares
|
|
|
3.3
|
Address (note 1)
|
Bonds
|
|
|
3.4
|
Current market value
|
Endowment policies
|
|
|
3.5
|
Debtor ownership %
|
Pension
|
|
|
3.6
|
Debtor’s interest (derived field)
|
Antiques
|
|
|
3.7
|
Monthly income
|
Precious metals/Jewellery
|
|
|
3.8
|
Is the asset located in the State? Yes □ No □
|
Prize Bonds
|
|
|
3.9
|
Comment
|
Livestock
|
|
|
|
|
Other - provide details
|
|
4
|
|
Plant, Equipment, Tools
|
|
|
|
4.1
|
Description
|
|
|
|
4.2
|
Current market value
|
|
|
|
4.3
|
Debtor ownership %
|
|
|
|
4.4
|
Debtor’s interest (derived field)
|
|
|
|
4.5
|
Is the asset located in the State? Yes □ No □
|
|
|
|
4.6
|
Comment
|
|
|
5
|
|
Vehicles
|
|
|
|
5.1
|
Make
|
|
|
|
5.2
|
Model
|
|
|
|
5.3
|
Year
|
|
|
|
5.4
|
Registration number
|
|
|
|
5.5
|
Kilometres
|
|
|
|
5.6
|
Need for vehicle
|
|
|
|
5.7
|
Current market value
|
|
|
|
5.8
|
Subject to finance? Yes □ No □
|
|
|
|
5.9
|
Balance outstanding
|
|
|
|
5.10
|
Monthly instalment
|
|
|
|
5.11
|
Adapted for disabled use? Yes □ No □
|
|
|
|
5.12
|
Is the asset located in the State? Yes □ No □
|
|
|
|
5.13
|
Comment
|
|
|
6
|
|
Stock in trade
|
|
|
|
6.1
|
Current market value
|
|
|
|
6.2
|
Is the asset located in the State? Yes □ No □
|
|
|
|
6.3
|
Comment
|
|
|
7
|
|
Money owed to you
|
|
|
|
7.1
|
Name of debtor
|
|
|
|
7.2
|
Address (note 1)
|
|
|
|
7.3
|
Book value
|
|
|
|
7.4
|
Realisable amount
|
|
|
|
7.5
|
Comment
|
|
|
8
|
|
Bank/Building Society Accounts
|
|
|
|
8.1
|
Name of bank/building society
|
|
|
|
8.2
|
Address (note 1)
|
|
|
|
8.3
|
Account Name
|
|
|
|
8.4
|
Account Number
|
|
|
|
8.5
|
Balance
|
|
|
|
8.6
|
Debtor ownership %
|
|
|
|
8.7
|
Debtor’s interest (derived field)
|
|
|
|
8.8
|
Comment
|
|
|
9
|
|
Credit Union Shares/Investment
|
|
|
|
9.1
|
Name of credit union
|
|
|
|
9.2
|
Address (note 1)
|
|
|
|
9.3
|
Account Name
|
|
|
|
9.4
|
Account Number
|
|
|
|
9.5
|
Current market value (less loan)
|
|
|
|
9.6
|
Debtor ownership %
|
|
|
|
9.7
|
Debtor’s interest (derived field)
|
|
|
|
9.8
|
Comment
|
|
|
10
|
|
Cash on hand
|
|
|
|
10.1
|
Amount
|
|
|
|
10.2
|
Is the asset located in the State? Yes □ No □
|
|
|
|
10.3
|
Comment
|
|
|
11
|
|
Prospective assets
|
|
|
|
11.1
|
Description
|
|
|
|
11.2
|
Estimated value
|
|
|
|
11.3
|
Estimated date of receipt
|
|
|
|
11.4
|
Is the asset located in the State? Yes □ No □
|
|
|
|
11.5
|
Comment
|
|
|
12
|
|
Contingent assets
|
|
|
|
12.1
|
Description
|
|
|
|
12.2
|
Estimated value
|
|
|
|
12.3
|
Estimated date of receipt
|
|
|
|
12.4
|
Is the asset located in the State? Yes □ No □
|
|
|
|
12.5
|
Comment
|
|
|
13
|
|
Other
|
|
|
|
13.1
|
Description
|
|
|
|
13.2
|
Estimated value
|
|
|
|
13.3
|
Is the asset located in the State? Yes □ No □
|
|
|
|
13.4
|
Comment
|
|
|
| | |
Liabilities - Detail
|
|
Questions common across all debt headings (except excluded debts):
|
|
|
1
|
Is this debt secured? Yes □ No □
|
|
|
|
|
If yes, security type:
|
|
|
|
|
Mortgage/charge
|
|
|
|
|
Other - if other please give details
|
|
|
|
|
What is the debt secured on?
|
|
|
|
2
|
Has any of this debt been incurred within 6 months of the application date? Yes □ No □
|
|
|
|
|
If yes, please state amount.
|
|
|
1
|
|
Principal Private Residence Lender
|
|
|
|
1.1
|
Account Number
|
|
|
|
1.2
|
Account Name
|
|
|
|
1.3
|
Contact details (note 2)
|
|
|
|
1.4
|
Current monthly payment due
|
|
|
|
1.5
|
Monthly repayments - actual
|
|
|
|
1.6
|
Remaining term (months)
|
|
|
|
1.7
|
Balance outstanding
|
|
|
|
1.8
|
Is the liability joint and several? Yes □ No □
|
|
|
|
1.9
|
If no, state % of liability
|
|
|
|
1.10
|
Amount of debtor’s liability (derived field)
|
|
|
|
1.11
|
Restructured? Yes □ No □
|
|
|
|
|
If yes please provide details
|
|
|
|
1.12
|
Current interest rate
|
|
|
|
1.13
|
Comment
|
|
|
2
|
|
Financial Institutions
|
|
|
|
2.1
|
Account Number
|
|
|
|
2.2
|
Account Name
|
|
|
|
2.3
|
Contact details (note 2)
|
|
|
|
2.4
|
Account Type*
|
Account Type*
|
|
|
2.5
|
Current monthly payment due
|
Mortgage
|
|
|
2.6
|
Monthly repayments - actual
|
Personal loan
|
|
|
2.7
|
Purpose of loan
|
Overdraft
|
|
|
2.8
|
Balance outstanding
|
Credit card
|
|
|
2.9
|
Is the liability joint and several? Yes □ No □
|
Store card
|
|
|
2.10
|
If no, state % of liability
|
Other – provide details
|
|
|
2.11
|
Amount of debtor’s liability (derived field)
|
|
|
|
2.12
|
Restructured? Yes □ No □
|
|
|
|
|
If yes please provide details
|
|
|
|
2.13
|
Comment
|
|
|
3
|
|
Credit Union
|
|
|
|
3.1
|
Account Number
|
|
|
|
3.2
|
Account Name
|
|
|
|
3.3
|
Contact details (note 2)
|
|
|
|
3.4
|
Current monthly payment due
|
|
|
|
3.5
|
Monthly repayments - actual
|
|
|
|
3.6
|
Purpose of loan
|
|
|
|
3.7
|
Balance outstanding (net liability)
|
|
|
|
3.8
|
Is the liability joint and several? Yes □ No □
|
|
|
|
3.9
|
If no, state % of liability
|
|
|
|
3.10
|
Amount of debtor’s liability (derived field)
|
|
|
|
3.11
|
Restructured? Yes □ No □
|
|
|
|
|
If yes, please provide details
|
|
|
|
3.12
|
Comment
|
|
|
4
|
|
Excludable Debts - Revenue
|
|
|
|
4.1
|
Description/Type*
|
Description/Type*
|
|
|
4.2
|
Contact details (note 2)
|
Income Tax
|
|
|
4.3
|
Permitted? Yes □ No □
|
VAT
|
|
|
4.4
|
If yes, creditor consent or deemed consent
|
PAYE/PRSI
|
|
|
4.5
|
If creditor consents, please scan letter of consent
|
Relevant Contracts Tax
|
|
|
4.6
|
If deemed consent, scan letter requesting consent
|
Local Property Tax
|
|
|
4.7
|
If no, have you sought consent from Revenue to have this debt permitted? Yes □ No □
|
Interest & penalties
|
|
|
4.8
|
Current monthly payment due
|
Other – provide details
|
|
|
4.9
|
Monthly repayments - actual
|
|
|
|
4.10
|
Balance outstanding
|
|
|
|
4.11
|
Preferential amount included in balance outstanding (where known)
|
|
|
|
4.12
|
Instalment arrangement? Yes □ No □
|
|
|
|
4.13
|
Amount of instalment
|
|
|
|
4.14
|
Comment
|
|
|
5
|
|
Excludable Debts - Other than Revenue
|
|
|
|
5.1
|
Description/Type*
|
Description/Type*
|
|
|
5.2
|
Contact details (note 2)
|
Local Government (Charges) Act 2009
|
|
|
5.3
|
Permitted? Yes □ No □
|
Rates - Local Government Act 2001
|
|
|
5.4
|
If yes, creditor consent or deemed consent
|
HSE (Nursing Homes Support Scheme Act 2009)
|
|
|
5.5
|
If creditor consents, please scan letter of consent
|
Service charges/contributions under MUD Act 2011
|
|
|
5.6
|
If deemed consent, scan letter requesting consent
|
Social Welfare Consolidation Act 2005
|
|
|
5.7
|
If no, have you sought consent from this creditor to have this debt permitted? Yes □ No □
|
Other – Provide details
|
|
|
5.8
|
Current monthly payment due
|
|
|
|
5.9
|
Monthly repayments - actual
|
|
|
|
5.10
|
Balance outstanding
|
|
|
|
5.11
|
Preferential amount included in balance outstanding (where known)
|
|
|
|
5.12
|
Comment
|
|
|
6
|
|
Employees
|
|
|
|
6.1
|
Description/Type*
|
Description/Type*
|
|
|
6.2
|
Contact details (note 2)
|
Arrears of wages
|
|
|
6.3
|
Current monthly payment due
|
Minimum notice
|
|
|
6.4
|
Monthly repayments - actual
|
Holiday pay
|
|
|
6.5
|
Balance outstanding
|
Redundancy
|
|
|
6.6
|
Preferential amount included in balance outstanding (where known)
|
|
|
|
6.7
|
Comment
|
|
|
7
|
|
Trade creditors
|
|
|
|
8.1
|
Contact details (note 2)
|
|
|
|
8.2
|
Current monthly payment due
|
|
|
|
8.3
|
Monthly repayments - actual
|
|
|
|
8.4
|
Balance outstanding
|
|
|
|
8.5
|
Comment
|
|
|
8
|
|
Connected creditors
|
|
|
|
9.1
|
Contact details (note 2)
|
|
|
|
9.2
|
Purpose of loan
|
|
|
|
9.3
|
Current monthly payment due
|
|
|
|
9.4
|
Monthly repayments - actual
|
|
|
|
9.5
|
Balance outstanding
|
|
|
|
9.6
|
Please specify the connection
|
|
|
|
9.7
|
Comment
|
|
|
9
|
|
Other debts
|
|
|
|
10.1
|
Description
|
|
|
|
10.2
|
Contact details (note 2)
|
|
|
|
10.3
|
Purpose of debt
|
|
|
|
10.4
|
Current monthly payment due
|
|
|
|
10.5
|
Monthly repayments - actual
|
|
|
|
10.6
|
Balance outstanding
|
|
|
|
10.7
|
Comment
|
|
|
10
|
|
Prospective debts
|
|
|
|
11.1
|
Description
|
|
|
|
11.2
|
Contact details (note 2)
|
|
|
|
11.3
|
Estimated amount
|
|
|
|
11.4
|
Estimated payment date
|
|
|
|
11.5
|
Comment
|
|
|
11
|
|
Contingent debts
|
|
|
|
12.1
|
Description
|
|
|
|
12.2
|
Contact details (note 2)
|
|
|
|
12.3
|
Estimated amount
|
|
|
|
12.4
|
Estimated payment date
|
|
|
|
12.5
|
Comment
|
|
|
12
|
|
Excluded debts
|
|
|
|
13.1
|
Current monthly payment due
|
|
|
|
13.2
|
Monthly repayments - actual
|
|
|
|
13.3
|
Balance outstanding
|
|
|
|
13.4
|
Comment
|
|
|
| | |
Note 1
Address
Country
Street (line 1)
Street (line 2)
Street (line 3)
Town
Zip/Postal Code
County
|
|
| | |
Note 2
Contact details:
Legal name of creditor
Country
Street (line 1)
Street (line 2)
Street (line 3)
Town
Zip/Postal Code
County
Email Address
Telephone Number
|
|
| | |
Monthly Income - Detail
|
|
|
|
€
|
|
|
Type of income
|
Amount
|
|
1
|
Salary/Wages - gross
|
|
|
|
Comment
|
|
|
2
|
Pension income
|
|
|
|
Comment
|
|
|
3
|
Income from self employment (before tax)
|
|
|
|
Comment
|
|
|
4
|
Rental income (net of expenses)
|
|
|
|
Comment
|
|
|
5
|
Income from investments
|
|
|
|
Comment
|
|
|
6
|
Contribution from household members
|
|
|
|
Comment
|
|
|
7
|
Income from boarders/lodgers
|
|
|
|
Comment
|
|
|
8
|
Income from State agencies
|
|
|
|
Comment
|
|
|
9
|
Child or Spousal Maintenance
|
|
|
|
Comment
|
|
|
10
|
Other
|
|
|
|
Comment
|
|
|
11
|
Department of Social Protection
|
|
|
11.1
|
Jobseekers Allowance/Benefit
|
|
|
|
Comment
|
|
|
11.2
|
Disability Allowance
|
|
|
|
Comment
|
|
|
11.3
|
Carer’s Allowance
|
|
|
|
Comment
|
|
|
11.4
|
Family Income Supplement
|
|
|
|
Comment
|
|
|
11.5
|
Rent Supplement
|
|
|
|
Comment
|
|
|
11.6
|
One Parent Family Payment
|
|
|
|
Comment
|
|
|
11.7
|
Child Benefit
|
|
|
|
Comment
|
|
|
11.8
|
Mortgage Interest Supplement
|
|
|
|
Comment
|
|
|
11.9
|
Other –Please specify
|
|
|
|
Details
|
|
|
|
Comment
|
|
|
|
Total income
|
|
|
| | |
Monthly Expenditure - Detail
|
|
|
|
€
|
|
|
Type of expenditure
|
Amount
|
|
1
|
Income Tax/ Social Insurance/Mandatory Pension
|
|
|
1.1
|
Income Tax
|
|
|
|
Comment
|
|
|
1.2
|
PRSI
|
|
|
|
Comment
|
|
|
1.3
|
Universal Social Charge
|
|
|
|
Comment
|
|
|
1.4
|
Mandatory Pension
|
|
|
|
Comment
|
|
|
1.5
|
Other - please specify
|
|
|
|
Details
|
|
|
|
Comment
|
|
|
2
|
General Expenses
|
|
|
2.1
|
Food
|
|
|
|
Comment
|
|
|
2.2
|
Clothing
|
|
|
|
Comment
|
|
|
2.3
|
Personal Care
|
|
|
|
Comment
|
|
|
2.4
|
Health
|
|
|
|
Comment
|
|
|
2.5
|
Household Goods
|
|
|
|
Comment
|
|
|
2.6
|
Household Services
|
|
|
|
Comment
|
|
|
2.7
|
Communications
|
|
|
|
Comment
|
|
|
2.8
|
Social Inclusion & Participation
|
|
|
|
Comment
|
|
|
2.9
|
Education
|
|
|
|
Comment
|
|
|
2.10
|
Transport
|
|
|
|
Comment
|
|
|
2.11
|
Household Electricity
|
|
|
|
Comment
|
|
|
2.12
|
Home Heating
|
|
|
|
Comment
|
|
|
2.13
|
Personal Costs
|
|
|
|
Comment
|
|
|
2.14
|
Savings & Contingencies
|
|
|
|
Comment
|
|
|
2.15
|
Home Insurance
|
|
|
|
Comment
|
|
|
2.16
|
Motor Vehicle Insurance
|
|
|
2.17
|
Childcare Costs
|
|
|
|
Comment
|
|
|
2.18
|
Other Expenses
|
|
|
|
Comment
|
|
|
3
|
Rent
|
|
|
|
Comment
|
|
|
|
Total Monthly Expenditure before debt repayment/arrears
|
|
|
4
|
Payments in relation to debt repayments/arrears
|
|
|
|
- Actual
|
Monthly Repayments
|
|
|
|
€
|
|
|
|
Current Monthly Payment Due
|
|
4.1
|
Principal Private Residence Lender
|
|
|
|
Comment
|
€
|
|
4.2
|
Financial Institutions
|
|
|
|
Comment
|
|
|
4.3
|
Credit Union
|
|
|
|
Comment
|
|
|
4.4
|
Excludable Debts -Revenue
|
|
|
|
Comment
|
|
|
4.5
|
Excludable Debts- other than Revenue
|
|
|
|
Comment
|
|
|
4.6
|
Employees
|
|
|
|
Comment
|
|
|
4.7
|
Trade Creditors
|
|
|
|
Comment
|
|
|
4.8
|
Connected Creditors
|
|
|
|
Comment
|
|
|
4.9
|
Other Debts
|
|
|
|
Comment
|
|
|
4.10
|
Excluded Debts
|
|
|
|
Comment
|
|
|
| |
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.
|
|
| |
The Minister for Justice consents to the making of the foregoing Regulations.
|
| |
|
| |
GIVEN under the Official Seal of the Minister for Justice,
|
| |
5 May, 2022.
|
| |
HELEN MCENTEE,
|
| |
Minister for Justice.
|
| |
|
| |
GIVEN under the seal of the Insolvency Service of Ireland,
|
| |
10 May, 2022.
|
| |
MICHAEL MCNAUGHTON,
|
| |
Director of the Insolvency Service of Ireland.
|
| |
EXPLANATORY NOTE
|
| |
(This note is not part of the Instrument and does not purport to be a legal interpretation)
|
| |
These Regulations amend the Personal Insolvency Act 2012 (Prescribed Financial Statement) Regulations 2014 (
S.I. No. 259 of 2014
) by substituting the form set out in Schedule 1 to these Regulations for the form set out in Schedule 1 to the Personal Insolvency Act 2012 (Prescribed Financial Statement) Regulations 2014 (
S.I. No. 259 of 2014
) and by substituting the form set out in Schedule 2 to these Regulations for the form set out in Schedule 2 to the Personal Insolvency Act 2012 (Prescribed Financial Statement) Regulations 2014 (
S.I. No. 259 of 2014
).
|
