SUBS0000058
Wy
Wy HERBERT
ITH
SM
By PREEHILLS
ZS
Applicant's details
1. Full name (including any middle
names)
Previous name(s) at time of
conviction (if any)
3. Date of birth
4. Current postal address
5. All previous addresses since date of
conviction (if different to the above
and if you have changed your
address since your conviction)
6. Email address
7. Contact telephone number
SUBS0000058_0001
SUBS0000058
Wy
Wy HERBERT
ITH
SM
By PREEHILLS
ZS
=
What was your role in connection
with Post Office (ie postmaster,
branch assistant/manager or Crown
Office employee)? If you were not a
postmaster, please provide further
details of your role (including length
and terms).
Application on behalf of someone else
9. Are you applying on behalf of
someone else? If yes, please set out
(i) your details, and (ii) your
relationship with the applicant.
Please also attach to this application
evidence of your authority to act on
the applicant's behalf.
Details of your potential civil claim against Post Office (please complete even if you have
sent a Letter of Claim to Post Office)
10. Please could you briefly explain what losses or damages you intend to claim for in your
"I civil claim and the expected value of your claim, where known.
1. In order to allow us to assess your claim, please confirm in particular whether you
intend to claim for the specific losses set out below. Please provide any further details
in respect of those claims, including the expected claim values.
a. Were you required to pay any money
at the time of or following your
conviction (eg did you repay a
shortfall or receive a confiscation
order or a compensation order)? If
so, please provide details.
b. Loss of reputation (including any
. loss of earning capacity) — if so,
please provide details
SUBS0000058_0002
WU
Wi, HERBERT
SUBS0000058
= = SMITH
ZS FREEHILLS
ANS
c. Loss of business or property
q. Personal injury or distress and
inconvenience
e Bankruptcy or insolvency related
costs or losses
f Prosecution related costs or losses —
if so please specify
g General damages such as loss of
. liberty, exemplary damages or
aggravated damages
A.
12.
Any other key heads of losses - if so,
please specify
nal Details
What was your annual income (gross
of tax) prior to your prosecution?
13.
What is your current income (gross
of tax)?
14.
Have you received any settlement
payments from Post Office in the
past (for example as part of the
Group Litigation or under Network
Transformation)? If so, please
provide details and confirm the
amount received.
15.
Do you receive any social security
benefits? If yes, please set out
details.
SUBS0000058_0003
se
Wy
WB. HERBERT
—
= suri
Zw FREEHILLS
4
SUBS0000058
=
°
Have you previously been, or are you
currently subject to, any bankruptcy
process, debt relief orders, individual
voluntary arrangements (IVAs),
company voluntary arrangements
(CVAs) or any other insolvency
procedures?
If yes, please set out details,
including the details of your assigned
Bankruptcy Trustee.
17.
By signing this document I confirm that all
of the information provided in this
application form is true and correct to the
best of my knowledge and belief.
If you are unable to print and scan this form
we will accept an electronic signature.
Please tick this box if you are submitting an
electronic signature.
i
Is there any further information or other relevant factors you would like us to consider
when assessing your interim payment application?
Statement of truth
Signed
Name
Date
SUBS0000058_0004