Application Form
POL00099705
POL00099705
Lend VAL Feat 23
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For Second Sight use only
Case ref: Nol /Me ot
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Your Details
Surname:
Wane EWZASETH
Forenames:
Your address:
Postcode:
Email address:
BinHe y
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: FAD Code of branch:
SMIMONS Veb-22b° b&
Address of branch: -
a2, Semucne Bp
NoexwanPront
Postcode: WHe bST
Your role at the branch (ie. Subpostmaster, Subpostmistress, clerk, etc.):
VBPesjymisteeIess
When did you begin in this role?
AePex AIS
Are you still in this role?
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If no, when did you leave this role:
POL00099705
POL00099705
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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.
pKNO
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? Lack eof Suppote qwen by Pest Shhree
No. — ad Manacets
ecqwpnenk Was Made, Re no. ima are
cake any losses Soncoslr and Nad no PesQe I
dor syste as\ors.
When did the incidents relating to the main issue or issues occur?
Bo1o- Ber1e
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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Ge enteraek® MANAGT
\ iu Qasmen Costar
Frvnaty. ee, ans Man Forncy \ ens
How was the issue or issues resolved at the time they occurred? 3
is
Bu \esses Were Paw to PO ak ww
oh eack Branch edia aN Pernod
What is the monetary value of the issue or issues you are now reporting?
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\eas wach Was {ve zen oS
Crasterheleh anc not tecuested
Hecanse SF om genq indeshaahon
POL00099705
POL00099705
Were you the subject of either civil recovery action or criminal prosecution regarding the main issue or
issues you are now reporting?
o
How were these actions against you (if any) resolved?
What is your explanation for the events forming the main issue or issues you are now reporting?
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Foyrsu, and ab\ ecqepnen was wRPlace
Aad loses stop —- SYeP eam plere\\ - B\nce
equpmaty wos changed Wy Soly- Bug sove
Demect Barances Nase Dean We Norm.
Did you request assistance from the Post Office regarding the issue or issues you are now reporting?
Wes
What assistance if any was provided?
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Leansacdkon \ocy Qrme - ok{s wich hac
almacku een elona. iam
Sys Ace .
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amen Cater
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equp mene. Wikece he sopperte TT Wink
Brat Yo woolda He we a vou mech Hoe
Please attach additional sheets of paper if you require more space.
pos non
POL00099705
POL00099705
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 help
reach a resolution with Post Office but that it may also reveal further claims against me.
° lam 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:
Currently serving as a Subpostmaster and have already raised my case with Post Office and have
completed all Post Office's internal complaint processes.
0 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 Workirig G , its members and their advisors owe no obligations or duties, and accept no liability,
to you in col uwith the Scheme.
Signed woe
Name DZS BRSwes
Date we SNS