O. 34A, r 2(5)

District No.

The information of ........... of ............., who says on Oath—

1 I am a member of the Defence Forces not below the rank of Colonel and a Superior Officer within the meaning of the Criminal Justice (Surveillance) Act 2009 which I hereinafter refer to as “the Act”.

2 I approved the carrying out of surveillance by approval under subsection (3) of section 7 of the Act, issued at ... am/pm on the ...... day of .......... 20 ... *(and varied at ....am/pm on the .... day of ........... 20 ... which approval continues in force until .... am/pm on the ...... day of ............. 20....

3 I have reasonable grounds for believing that surveillance beyond the period of 72 hours is warranted.

4 I hereby apply under section 4(4) of the Act, read in conjunction with section 7(10) of the Act, for an Authorisation to continue surveillance (within the meaning of that word as provided for in section 1 of the Act). I set out the details of the surveillance for which I seek such an Authorisation and of the surveillance device within the meaning of that phrase as provided for in section 1 of the Act in my information hereunder.

5 *I believe that the surveillance being sought to be authorised to continue is necessary for the purpose of maintaining the security of the State. I give details of the grounds for so believing in this my information hereunder.

6 I believe that the surveillance being sought to be authorised to continue is

(a) the least intrusive means available, having regard to the objectives and other relevant considerations,

(b) proportionate to its objectives, having regard to all the circumstances including its likely impact on the rights of any person, and

(c) of a duration that is reasonably required to achieve its objectives.

*7. I believe that for the purposes of the Authorisation sought, it will be necessary for the Defence Forces to enter, if necessary by the use of reasonable force, a place, namely.................., for the purposes of initiating or carrying out the surveillance to be authorised, and withdrawing the authorised surveillance device, without the consent of a person who owns or is in charge of the said place.

8. The period during which the surveillance is intended to continue to be carried out is from the .... day of ........ 20 ... to the .... day of ...... 20... (being a period not exceeding three months).

I say further and give the following information:

9. Details of the surveillance being sought to be authorised to continue:—

........................

10. Details of the surveillance device intended to be used for the surveillance sought to be authorised to continue

........................

11. My grounds for believing that the surveillance being sought to be authorised to continue is necessary for the purpose of maintaining the security of the State are:—

........................

12. My grounds for believing that the surveillance being sought to be authorised to continue is the least intrusive means available having regard to the objectives and to other relevant circumstances are:—

........................

13. My grounds for believing that the surveillance being sought to be authorised to continue is proportionate to its objectives having regard to all the circumstances and its likely impact on the rights of any person are:—

........................

14. My grounds for believing that the duration of the surveillance sought to be authorised to continue is reasonably required to achieve its objectives are:—

........................

15. A copy of the written record of approval under subsection (3) of section 7 of the Act *(as so varied), marked with the letter “A”, the contents of which I believe are true and accurate is attached.

16. A summary of the results of the surveillance carried out pursuant to that approval is as follows:

........................

17. My grounds for believing that continued surveillance is warranted are the following:

18. The reasons why continued surveillance is required are the following:

........................

*19. My grounds for believing that for the purposes of the Authorisation sought, it will be necessary for the Defence Forces to enter, if necessary by the use of reasonable force, a place, namely ........., for the purposes of initiating or carrying out the surveillance to be authorised, and withdrawing the authorised surveillance device, without the consent of a person who owns or is in charge of the said place, are as follows:

........................

AND I hereby apply under section 4(4) and section 7(10) of the Act for an Authorisation under section 5 of the Act continuing the surveillance proposed for the period of ......... from the issue of the said Authorisation to the .... day of .......... 20.... (being a period not exceeding three months)

*AND I apply that an Authorisation granted under section 5 of the Act should authorise *me as the Superior Officer so authorised/*a member of the Defence Forces designated by me as the Superior Officer so authorised, accompanied by any other person whom *I consider/*said member considers necessary, to enter, if necessary by the use of reasonable force, the said place for the purposes of initiating or carrying out the authorised surveillance, and withdrawing the authorised surveillance device, without the consent of a person who owns or is in charge of the said place.

Signed: ..............

Informant

Sworn before me this .... day of .......... 20...

Signed: ..................

Judge of the District Court

* Delete any words or paragraphs which are inapplicable, including any options which do not apply to the case