Statutory Declaration Form For Lost/stolen Permits printable pdf download

KILKENNY BOROUGH COUNCIL

COMHAIRLE BUIRGE CHILL CHAINNIGH

Tel: 056 7794540 Fax: 056 7794527 email:

trafficfines@kilkennycity.ie

Statutory Declaration Form For Lost / Stolen Permits

I,_________________________________________________________________________

Name in Block Capitals

of_________________________________________________________________________

Address in Block Capitals

do solemnly and sincerely declare and say as follows:-

1. I refer to my application dated the ____________ day of _________________20________

for a Resident’s Parking Permit in respect of Vehicle Registration No: __________________

2. I do hereby solemnly and sincerely declare and confirm that my principal place of residence is at

the above address and my current permit has been lost/stolen.

I make this solemn declaration conscientiously believing the same to be true and by virtue of the

Statutory Declarations Act, 1938.

_______________________________

Signature of Applicant

SWORN / DECLARED by __________________________________this______________

day of ________________________ 20____ at ___________________________________

In the Borough of Kilkenny ________________________ before me a Peace Commissioner /

Commissioner for Oaths/Practising Solicitor, (delete whichever is in applicable) and I know the

declarant.

Stamp

Signature: _________________________

(Block Capitals) Name: _________________________

Address: _________________________

Note:

o It is an offence under Section 6 of the Statutory Declaration Act, 1938 for any person to make a

Statutory Declaration which to his knowledge is false or misleading in any material respect. The

penalty on summary conviction is a fine not exceeding €60 or, at the discretion of the Court, to

imprisonment for a term not exceeding three months or to both such fine and such imprisonment.

o Applicants are advised that completed application form together with all submitted documentation

in support of application will be required to be retained by Kilkenny Borough Council for the

purposes of audit inspection by both the Local Government Auditor and the Borough Councils

Internal Auditor for a period of no longer than two and a half years.

Note: Applications will not be accepted unless declaration is FULLY COMPLETED

Statutory Declaration Form For Lost/stolen Permits