POL00099688
POL00099688
6
Application Form
For Second Sight use only
Case ref: MM olf
Your Details
Surname: Forenames:
Thomas RUGHIE No&L
Your address:
Postcode:
Telephone number 1: Email address:
My current Member of Parliament is:
Me. ArgerrT OWEN MP
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: a FAD Code of branch:
GAERWEN , Yas Mon [60 boue2z
Address of branch: ao
Tue Pose oericé , GneeweN,
Yuys Mon
Postcode: libe bob
Your role at the branch (ie. Subpostmaster, Subpostmistress, clerk, etc.):
Sug posrma s7ER
‘When did you begin in this role? Are you still in this role?
14 Wy O YES
; BO
Ifo, when did you leave this role: Coos
POL00099688
POLO0099688
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)?
O YES — you may still submit your case, but Second Sight may not be able investigate it whilst criminal
investigations or proceedings are on-going.
NO
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?
Tue Teaming wads Inaveguatt — Bore iw REcation To THE
DEPTH OF KNowece dae REQUED ANA MveATION of IRAINID
THe BACK UF PRovibtD Was INSUFELCLEAST.
THe SueTem Was UNFoeetVING ANS bib Nor ENAme £24
eo b€ CoteecTEeb.
When did the incidents relating to the main issue or issues occur?
Peioe T ood
What prior contact have you had with the Post Office in regard to the incidents/issues that you are now
reporting?
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me Issves weee Canvatse® Wen Tue Pogr oFeive
INVEXTIGATEN — T Have Arwayh Mainstaineh THIS Raid
How was the issue or issues resolved at the time they occurred?
IN 2E CATION TO ONE INCI BENT
g RekotvES ON & So: So
NY
AT ome TIME, '
Paercur ar We BiscrePancy WA
Baus — Wick The Pose OFFICE Consrer Sur in&® I Seen
What is the monetary value of the issue or issues you are now reporting?
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TAL
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Disgarree — MY Hovve 4 Bosmess Fremueey, wy Ww
pe
to RS
=
—
Mee Wor, WE Lose ace ave JAVINGS + [NSUCANCES
Twas vNage To Compnve AS A Covsn Covucateos,
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POLO0099688
POL00099688
Were you the subject of either civil recovery action or criminal prosecution regarding the main issue or
issues you are now reporting?
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Acuounminé. 7 va Been Svptecx« of A
Peoceess of cCaime Ace Aprucarion
How were these actions against you (if any) resolved?
e OF
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fase Accountisg and kesr TO Pes8oN
Twas oeneecdD “To MAE PAYMENTS TO tHe
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What is your explanation for the events forming the main issue or issues you are now reporting?
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Why
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Did you request assistance from the Post Office regarding the issue or issues you are now reporting?
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pages aA Wat bans I
What assistance if any was provided?
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wan oh, VE don - (Ra Ruel Location — Tra wer
yo-ms Une +o turn te .
Please attach additional sheets of paper if you require more space.
mystinn Hem my Beth BM
POL00099688
POL00099688
Declaration
I acknowledge that:
. As part of the Scheme, I must promptly provide information about my case to Second Sight. If!
do not provide full information in a timely 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 heip
feach a resolution with Post Office but that it may also reveal further claims against me.
. 1 am only 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.
whet 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, its members and their advisors owe no obligations or duties, and accept no liability,
to you in connectian.with the Scheme...
Signed