District No.

........... Plaintiff of ...............

........... Defendant of ...............

WHEREAS in the above-named civil proceedings now before the Court, brought by the above-named plaintiff seeking damages against the above-named defendant in respect of *personal injury *loss suffered by the plaintiff resulting from the following offence committed by the defendant, that is to say,—

THE COURT HAS ASSESSED the damages that the plaintiff would be entitled to recover in respect of the said *injury *loss at £..... ,

AND IT APPEARING to the Court—

that on the ... day of ...... 19..... a compensation order under section 6 (1) of the above-mentioned Act was made against the defendant in respect of the said *injury *loss by the ................. Court, and that the defendant has paid the sum of £ as compensation to the plaintiff in compliance with the terms of the order,

NOW THE COURT, being satisfied that the amount paid by the defendant to the plaintiff under that order exceeds the amount of the damages as assessed in these civil proceedings,

HEREBY ORDERS that the amount of the excess, that is to say, the sum of £ .... , be repaid by the plaintiff to the defendant,

AND COMMANDS all sheriffs and county registrars to take in execution the goods of the plaintiff to satisfy the said last-mentioned sum.

Dated this .... day of ......... 19 .... .

Signed .........................

Judge of the District Court

*Delete words inapplicable