Barack 4 (IRENE THE WOBLENS one).
Bana: BINA POMG FAS = 859 GUT
Merkese boos ocring PAU Stk,
BACARRA ©
ab EW oe with,
REBIBIOd,
S403. ey
WH Raye - SW -Roo“nnaceg .
KECka Mtte i. Boos Jab
NWT SHILL 1a THe Royg
POL00099686
POL00099686
Application Form
POLO0099686
POLO0099686
Kacewed (St figh 200
(ms /)
For Second Sight use only
Mo/§
Case ref:
Your Details
Surname:
Forenames:
AKA Kho
Postcode:
w
Your address:
Telephone number 1:
Telephone number 2:
My current Member of Parliament i Teak WVAKAQ ws
RUNAWAN SAN)
Your Branch ® :
Please insert the details of the branch where you worked. If you worked at more than one branch,
please provide details on an extra sheet of paper.
Name of branch:
LLASERQ IBA
FAD Code of branch:
(ol bx
Postcode:
Address of branch:
NEW STREET KAAFARIAA ,
enero lea itioa I
Your role at the branch (ie. Subpostmaster, Subpostmistress, clerk, etc.):
Sub-bo@7masTek .
When did you begin in this role?
l-\-9% °
Are you still in this role?
O YES
NO
if no, when did you ieave this role:
POL00099686
_ POLO0099686
Initial Case Overview
To the best of your knowledge, is your case (or any part of it) currently subject to any on-going criminal
investigations or proceedings (including the issue of a summons, sentencing hearings or a confiscation
order)?
0 YES — you may still submit your case, but Second Sight may not be able investigate it whilst criminal
investigations or proceedings are on-going.
Jno
The purpose of the 'Initial Case Overview' is to summarise the main issues you wish Second Sight to
consider. If your case is accepted for mediation, you will then have an opportunity to supply much more
detail together with supporting evidence.
The following Key Questions may help you with this Initial Case Overview but please feel free to supply
any information that you consider may help explain your complaint.
What is the main issue or issues you wish us to consider that relate to Horizon or its associated
processes?
RDU To FRAKTY ERALIMERT bok WWNMAIETodS Ads HKG
S WoW I MRD WE UH GE ShUdGE
\ S of Kos/
MOK Zo KAWAE WY : ove \
Re DEK agate Re Neoveh “9 Mt
hen did the in he th Or \ssues occur?
BBO, AX-r 0 AT 12 OG I
1h. WW Ys
What prior contact have you had with the Post Office in regard to the incidents/issues that you are now
reporting?
\ WR RsaTiayghy REPATES FRAKS WITH THE Sue
‘ TEM
FRAY ROSTER Tena SCAN, WNABLE 4o_ ORES gee
BR WERE A AAIME QO iK% REOAK dh SEQ ADIT . wane
How was the issue or issues resolved at the time they occurred? ¢ SH, L0G VK WE w area
ME OED
(
\ Was Zo Revey te am
\ WATS TYorr
Wis (Mera RetoMes 17 oa Le MOM EH I
To TUE Load
ASS Be S-Sp -[euswe) 1 Ce hee : Wh Wwe i
What is the monetary value of the issue or issues you are now reporting? SS Wake .
1. PAI% 104.
y Par
POLOO099686
POLO0099686
Were you the subject of either civil recovery action or criminal prosecution regarding the main issue or
issues you are now reporting?
NY.
How were these actions against you (if any) resolved?
y,
What is your explanation for the events forming the main issue or issues you are now reporting?
AWE Vouree Fpl Zo Flax Ady Kure vee of eanw (ape
AVE opi OTHER Extinaacina 18 A FRULC a FRUKS Wor,
UN w WoWitoa VSTEM _ 1 AAD WATE OR As VEY of
ENS Row AMC Laeg Naaiva aN DALY LOTR ans
AES sie Ponty BANS EE SAG the’ SIZ 2Rues Shou “S) feporting?
MES. OP SEVERN O0eKIoS,
What assistance if any was provided? (Ay any fe ku
\ Retorse> WHE WATER To THE V9 Worse
WE 1AIAL RE MOK Lop WK Ko Leomeas (AaelY BWwhers ug
Cham wy (o7e hes Qenkas Kewnc, . NY Wats
Ci Se NS Ba MAS Co Fu A NEM Lad
G WRT Morne FEN SHO spacf OAC -
Please attach
POLOO099686
POL00099686
Declaration
I acknowledge that:
. As part of the Scheme, I must promptly provide information about my case to Second Sight. If I
do not provide full information in a timeiy manner, i accept that it may not be possible to
investigate or mediate my case.
° Information i provide about my case or the findings of Second Sight's investigation may help
reach a resolution with Post Office but that it may also reveal further claims against me.
. I am oniy entitled to financial support from Post Office if I have signed a Funding Agreement.
I confirm that:
. My case relates to the Horizon system or an associated issue.
. Post Office may communicate details of my case to Second Sight, JFSA, my Member of
Parliament and/or its professional advisors.
. The facts and matters set out in this Application are true and accurate to the best of my
knowledge and belief.
I confirm that I am:
O Currently serving as a Subpostmaster and have already raised my case with Post Office and have
completed all Post Office's internal complaint processes.
Z Not currently serving as a Subpostmaster.
(Please tick one box)
If you are unable to give all the above acknowledgements and confirmations, your case may not be
eligible for the Scheme. In that circumstance, please contact the JFSA for assistance.
This Application Form and your involvement in the Scheme do not create any legally binding contract or
obligations between Post Office and you.
The Working Group, (t members and their advisors owe no obligations or duties, and accept no liability,
to you in connectic
Signed
Name
Date