District No.

........... Applicant

of ........

............ Injured Party

of ..................

WHEREAS on the ... day of .......... 19.... , on conviction of the above-named applicant of an offence, THE COURT MADE A COMPENSATION ORDER under section 6 (1) of the above-mentioned Act ordering the applicant to pay the sum of £ as compensation to the above-named injured party who suffered *personal injury *loss resulting from *(that offence) *(an offence taken into consideration in determining sentence), and directing that the said compensation be paid *(in one payment) * (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 WHEREAS because of a substantial reduction in his/her means, the applicant claims that these means are insufficient to satisfy that order in full,

TAKE NOTICE that the applicant will apply at the sitting of the District Court to be held at ........ on the ... day of ........ 19 at a.m./p.m. for an order under section 6 (8) (a) of the said Act—

* reducing the amount remaining to be paid

* varying (an) instalments) payable

* directing that no payments/further payments be made under the compensation order.

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

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

Applicant/Solicitor for applicant

To

of

The above -named injured party.

*Delete words inapplicable