se
NZ HERBERT
= SMITI
AIS PREEHILLS
Applicant's details
SUBS0000059
1 Full name
2 Previous name(s) at time of
conviction (if any)
3 Postal address
4 Email address
5 Contact telephone number
What was your role in connection
with Post Office (ie postmaster,
branch assistant/manager or
6 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
Are you applying on behalf of
someone else? If yes, please set
out (i) your details, and (ij) your
relationship with the applicant.
Please also attach to this
application evidence of your
authority to act on the applicant's
behalf.
SUBS0000059_0001
Wy
iy = HERBERT
= SMITH
AIS FREEHILLS
SUBS0000059
a Letter
Details of your potential civil claim against Post Office (please complete even if you have sent
of Claim to Post Office)
Please could you briefly explain what losses or damages you intend to claim for in
your civil claim and the expected value of your claim, where known.
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.
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.
Loss of reputation (including any
loss of earning capacity) — if so,
please provide details
Loss of business or property
SUBS0000059_0002
Ly
é%
. NZ HERBERT
= SMITI
AIS PREEHILLS
SUBS0000059
Personal injury or distress and
10
a. inconvenience
Bankruptcy or insolvency related
& costs or losses
f Prosecution related costs or
. losses — if so please specify
General damages such as loss of
g- liberty, exemplary damages or
aggravated damages
h. Any other key heads of losses - if
- so, please specify
jonal Det:
What was your annual income
(gross of tax) prior to your
prosecution?
11
What is your current income
(gross of tax)?
12
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.
13
Do you receive any social security
benefits? If yes, please set out
details.
14
Have you previously been, or are
you currently subject to, any
SUBS0000059_0003
NZ HERBERT
MIT]
S_PREEHILLS
7S
77
NZ
Date
Letter to
SUBS0000059
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.
15
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.
Js 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
SUBS0000059_0004