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District Court Rules

Schedule: B - Forms in criminal proceedings

Form: 10.3 Statutory declaration as to personal service

S.I. No. 285 of 2012

No. 10. 3

Download & fill in this form
Schecule B - Form 10.3 - S.I. No. 285 of 2012.pdf
O.10, r16

Statutory Declaration As To Personal Service

I, ................... of ............... aged 16 years and upwards, do solemnly and sincerely declare that:

I duly served this original document on the ........ day of ............ 20 ......,

by handing a copy thereof to*............... and I make this solemn declaration conscientiously believing the same to be true and by virtue of the Statutory Declarations Act 1938.

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

Declared before me .................[name in capitals] a †(Judge of the District Court) †(commissioner for oaths/practising solicitor) †(peace commissioner) † (notary public) by the said ..................

†[who is personally known to me],

†[who is identified to me by ............ who is personally known to me]

†[whose identity has been established to me before the taking of this Declaration by the production to me of

††passport no. ............ issued on the ........ day of .......... by the authorities of ........., which is an authority recognised by the Irish Government,

††national identity card no. ............. issued on the ........ day of ........... by the authorities of ............. which is an EU Member State, the Swiss Confederation or a Contracting Party to the EEA Agreement,

††Aliens Passport no. ............ issued on the ........ day of ....... by the authorities of ......... which is an authority recognised by the Irish Government,

††refugee travel document no. ........... issued on the ........ day of ........ by the Minister for Justice and Equality,

††travel document (other than refugee travel document) .......... issued on the ...... day of .......... by the Minister for Justice and Equality,]

at ............... this ..... day of .............. 20 ......

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

†Judge of the District Court/†Commissioner for Oaths/†Practising Solicitor/†Peace Commissioner/†Notary Public

*Give full particulars of service

†Delete words or clauses which are not applicable.

††Where relevant, provide details of the document by which identity has been established, and delete the remaining alternatives.