District No.

....... Prosecutor

....... Accused

....... Injured Party

WHEREAS IN PROCEEDINGS entitled as above THE COURT has on this day CONVICTED the above-named accused (hereinafter referred to as the "convicted person") residing at ...........

*(in the court area and district aforesaid) of the following offence, that is to say,—

AND WHEREAS the above-named injured party has suffered *personal injury *loss resulting from *(that offence) *(the following offence(s) which was/were taken into consideration in determining sentence, that is to say,—

),

NOW THE COURT, considering that it would be appropriate to make a compensation order in respect of the said *injury *loss,—

having regard to

the evidence given and the representations made herein, and

the means of the convicted person so far as they appear or are known to the Court,

and

being of opinion that the total amount required by this order to be paid does not exceed the amount of the damages that the injured party would be entitled to recover in a civil action against the convicted person in respect of the said *injury *loss,

HEREBY ORDERS pursuant to section 6 (1) of the Act that the said convicted person ....... do pay the sum of £ ..... as compensation in respect of the said *injury *loss to the said injured party ....... of ......... , who has suffered such *injury *loss,

AND DIRECTS that such compensation be paid—

*(in one payment, such payment to be made not later than the ... day of ........... 19 ..... , )

*(by .......... consecutive *weekly *monthly instalments of £ each and a final balance

of £ , the first of such instalments to be paid on the ... day of ......... 19 ...... ,)

AND FURTHER DIRECTS that all payments made under this order shall be made to the

District Court Clerk,

District Court Office,

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

for transmission to the injured party.

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

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

Judge of the District Court

NOTE

The operation of the above order shall be suspended until the ordinary time for giving notice of an appeal (whether against the conviction to which the order relates or the sentence or the order itself) has expired, that is to say, until the expiration of fourteen days from the date of the conviction, sentence or order.

(See subsections (1) and (4) of section 8 of the Act)

* Delete words inapplicable.