PIA Initiation
S.I. No. 332/2013 –
Personal Insolvency Act 2012 (Prescribed Protective Certificate Debt Settlement Arrangement Application Form) Regulations 2013.
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Notice of the making of this Statutory Instrument was published in
The Regulations
“Iris Oifigiúil” of 3rd September, 2013.
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) (the “Act”), hereby makes the following regulations:
1. These Regulations may be cited as the Personal Insolvency Act 2012 (Prescribed Protective Certificate Debt Settlement Arrangement Application Form) Regulations 2013.
2. The form set out in the Schedule to these Regulations is hereby prescribed for the purposes of section 59(2) of the Act.
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Schedule
APPLICATION FOR PROTECTIVE CERTIFICATE
(DEBT SETTLEMENT ARRANGEMENT)
*AN CHÚIRT CHUARDA
*[THE CIRCUIT COURT] *[THE HIGH COURT]
*PERSONAL INSOLVENCY ACT 2012
*[………………..] CIRCUIT *COUNTY OF [………………..]
IN THE MATTER OF AN APPLICATION UNDER SECTION 61 OF THE PERSONAL INSOLVENCY ACT 2012
AND IN THE MATTER OF ..]
OF [..],
A DEBTOR
*I/*We …………..
of …………..
County of …………..
*and …………..
of …………..
County of …………..
HEREBY APPLY for the making of an order for the issue under section 61(2)(a) of the Personal Insolvency Act 2012 of a protective certificate.
Dated.20..
* Delete where inapplicable
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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 59(2) of the Act.
3. The Insolvency Service may request any further information it requires from a debtor (the “Debtor”) or personal insolvency practitioner 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as the Insolvency Service may (at its discretion) permit, will mean that the application shall be deemed to have been withdrawn.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. Where the personal insolvency practitioner becomes aware of any inaccuracy or omission in this application or any document accompanying this application, he or she is required under section 59(4) of the Act to inform the Insolvency Service of this fact as soon as practicable.
5. 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 dsa@isi.gov.ie
6. 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.
7. This application may be withdrawn at any time prior to the issue of a protective certificate in accordance with section 59(3) of the Act.
8. This application shall be accompanied by the prescribed fee and the following documentation:
(a) a statement of the personal insolvency practitioner prepared under section 54 of the Act;
(b) the Debtor’s signed confirmation that he or she satisfies the eligibility criteria specified in section 57 of the Act;
(c) the Prescribed Financial Statement;
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(d) the statutory declaration of the Debtor referred to in section 57(1)(c) of the Act;
(e) a schedule of creditors of the Debtor and the debts concerned, stating in relation to each such creditor the information specified in section 59(2)(e) of the Act;
(f) the Debtor’s written consent to the disclosure and processing of his or her personal data of the Debtor as specified in section 59(2)(f) of the Act;
(g) the Debtor’s written consent to the making of any enquiry under section 60 of the Act relating to the Debtor by the Insolvency Service;
(h) such other documentation as may be requested in this application
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Application Form
APPLICATION QUESTIONS
Is this an individual application or a joint application?If this is a joint application each Debtor must complete the “Debtor’s Details” sections.
Individual Joint
Are the total liabilities of the Debtor determined on the basis of the Prescribed Financial Statement completed by the Debtor in respect of this application in excess of €2,500,000?
Yes No
Have 25% or more of the Debtor’s debts (other than excluded debts and secured debts) been incurred during the period of 6 months ending on the date of this application?
Yes No
(DEBTOR’S DETAILS sections to be completed by all debtors in the case of a joint application)
DEBTOR’S DETAILS – Initial Information
Has the Debtor received advice from the personal insolvency practitioner on the matters set out in section 52 of the Act?
Yes No
Was the advice referred to in section 52(1)(c) of the Act confirmed in writing by the personal insolvency practitioner to the Debtor?
Yes No
Has the Debtor instructed the personal insolvency practitioner in writing to make a proposal for a Debt Settlement Arrangement in accordance with Chapter 3 of the Act?
Yes No
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.
Yes No
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DEBTOR’S DETAILS – Initial Information
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.
Yes No
DEBTOR’S DETAILS – Personal Details
Surname:
First name:
Name as it appears on birth certificate:
Is the Debtor or has the Debtor been known by any other name? If yes, please supply name(s):
Yes No Name(s):
Title:*
Mr
Mrs
Miss
Ms
Other (please specify)
Gender:*
MaleFemaleOther
PPS number:
Date of birth:
Country of birth:
Nationality:
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DEBTOR’S DETAILS – Personal Details
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 divorce/annulment) Civil partnership
Separated
Divorced
Widow/Widower
Current Address:
Home telephone number:
Mobile telephone number:
Email address:
DEBTOR’S DETAILS – Previous Addresses
Has the Debtor had any previous addresses in the last 5 years?
If yes, please supply address(es):
Yes No Address(es):Start date and end date:
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DEBTOR’S DETAILS – Employment Status
What is the Debtor’s current employment status?*
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:
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?
If not, what is the percentage of the Debtor’s ownership of the business?
Yes No Percentage:
When did the business start trading?
Please specify a year and a month.
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DEBTOR’S DETAILS – Previous Businesses
Has the Debtor ever carried on a business, other than that referred to in the Employment Status section above, under a trading/business name or any other name other than the Debtor’s current name?
If yes, please supply all previous name(s) and address(es)
Yes No Name(s) and Address(es):Start date and end date:
DEBTOR’S DETAILS – Insolvency Status
Is the Debtor an undischarged bankrupt?
Yes No
Is the Debtor a discharged bankrupt subject to a bankruptcy payment order?
Yes No
Is the Debtor a person who is a specified debtor as respects a Debt Relief Notice which is in effect?
Yes No
Is the Debtor a person who, as a debtor, is subject to a Personal Insolvency Arrangement which is in effect?
Yes No
Is the Debtor a person who, as a debtor, is subject to an arrangement under the control of the court under Part IV of the Bankruptcy Act 1988 ?
Yes No
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DEBTOR’S DETAILS – Prior Insolvency Processes
Has the Debtor been the subject of a protective certificate issued under section 61 of the Act less than 12 months prior to the date of this application?
Yes No
Has the Debtor had his or her debts discharged pursuant to section 46(1) of the Act less than 3 years prior to the date of this application?
Yes No
Has the Debtor had his or her debts discharged pursuant to a Personal Insolvency Arrangement less than 5 years prior to the date of this application?
Yes No
Has the Debtor been discharged from bankruptcy less than 5 years prior to the date of this application?
Yes No
Has the appropriate court made an order referred to in section 57(2) of the Act stating that it is satisfied that the current insolvency of the Debtor arises by reason of exceptional circumstances or other factors which are substantially outside the control of the Debtor and that it would be just to permit the Debtor to make a proposal for a Debt Settlement Arrangement?
If yes, please provide a copy of the order with this application.
Only to be answered if any of the previous four questions are answered in the positive.
Yes No
Has the Debtor ever entered into a Debt Settlement Arrangement?
Yes No
DEBTOR’S DETAILS – Other Eligibility Criteria
Is the Debtor domiciled in the State, or within one year before the date of this application, has the Debtor ordinarily-
(i) resided in the State, or
(ii) had a place of business in the State?*
Yes No
Domiciled
Resided
Business
Is the Debtor insolvent within the meaning of the Act?
Yes No
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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 Living Expenses Guidelines”), is this a one adult household or a two adult household?*
One adult householdTwo adult household
Does the Debtor have any dependent children (under 19 years of age) living with him or her?
If yes, complete -Reasonable Living Expenses – Children.
Yes No
Does the Debtor own a motor vehicle?
Yes No
If yes, does the Debtor require a motor vehicle?
Yes No
The monthly total set costs under the Reasonable Living Expenses Guidelines for the Debtor’s typical household are:
€
Does the Debtor have any childcare costs?
If yes, please give the monthly expenditure amount assessed to be reasonable by the personal insolvency practitioner in accordance with the Reasonable Living Expenses Guidelines.
Yes No Monthly amount: €
How much is the Debtor’s monthly rent, mortgage repayment or other accommodation costs assessed to be reasonable by the personal insolvency practitioner in accordance with the Reasonable Living Expenses Guidelines?
€
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.
Yes No
In the case of a two adult household, has the Debtor rebutted the presumption of an equal split of the reasonable living expenses between them?
Yes No
What percentage of the Debtor’s household reasonable living expenses should be attributed to the Debtor?
Percentage:
The Debtor’s reasonable living expenses are:
€
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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 amount and details of this expenditure.
Monthly amount: €Details:
JURISDICTIONOnly applicable if Circuit Court Application
With reference to section 5(2) of the Act, please specify relevant County of the Debtor:
Circuit Court:
Reason for specifying County:*
Debtor residing at the time ofthis applicationDebtor resided within one yearof the time of this applicationDebtor has a place ofbusiness at the time of this applicationDebtor had a place of businesswithin one year of the time ofthis application
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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.
http://www.irishstatutebook.ie/images/ls
GIVEN under the seal of the Insolvency Service of Ireland,
30 August 2013.
LORCAN O’CONNOR,
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 prescribe the form to be used when making an application to the Insolvency Service of Ireland for a protective certificate in respect of a proposal for a Debt Settlement Arrangement.
S.I. No. 228/2022 –
Personal Insolvency Act 2012 (Prescribed Financial Statement) (Amendment) Regulations 2022
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:
1. These Regulations may be cited as the Personal Insolvency Act 2012 (Prescribed Financial Statement) (Amendment) Regulations 2022.
2. In these Regulations “Principal Regulations” means the Personal Insolvency Act 2012 (Prescribed Financial Statement) Regulations 2014 (S.I. No. 259 of 2014).
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.
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.
SCHEDULE 1
Case Ref No.:
PRESCRIBED FINANCIAL STATEMENT
Debt Relief Notice
Name of Debtor:
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)
Qualifying debts
Non-Qualifying 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
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
Department of Social Protection
Income – Other
__________
Total income
__________
Expenditure (monthly)
€
Income Tax / Social Insurance/Mandatory Pension
Reasonable Living Expenses – set costs per guide
Reasonable Living Expenses – rent/mortgage
Reasonable Living Expenses – Motor Vehicle Insurance
Reasonable Living Expenses – Home Insurance
Reasonable Living Expenses – childcare costs
Reasonable Living Expenses – special circumstances
Payments in respect of Excluded Debts
Payments in respect of Excludable Debts not permitted
__________
Total Monthly Expenditure
__________
__________
Net disposable income
__________
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?
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
Amount due
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
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
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
Amount due (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
Amount due
Interest & penalties
4.8
Preferential amount included in amount due (where known)
Other – provide details
4.9
Instalment arrangement? Yes □ No □
4.10
Amount of instalment
4.11
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
Amount due
Other – provide details
5.8
Preferential amount included in amount due (where known)
5.9
Comment
6
Employees
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
Trade creditors
8.1
Contact details (note 2)
8.2
Amount due
8.3
Comment
8
Connected creditors
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
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.
/images/ls
GIVEN under the Official Seal of the Minister for Justice,
5 May, 2022.
HELEN MCENTEE,
Minister for Justice.
/images/ls
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 ).