Ex Gratia Scheme Application Form

• Published date: 21 July 2021
• Issuer: Department of Education

Ex Gratia Scheme Application Form

Please read the Terms of Scheme prior to completion.

Name: ___________________________________________________________________________

Date of Birth: ______________________________________________________________________

Address: _________________________________________________________________________

_________________________________________________________________________________

Name and Address of School: _______________________________________________________

_______________________________________________________________________________

Name of abuser: ___________________________________________________________________

Role of abuser in the school: __________________________________________________________

Dates that abuse took place: __________________________________________________________

The application form must be accompanied by:

 proof of identity including date of birth, for example, copy of birth certificate, passport, driving

licence

 supporting evidence of sexual abuse (as outlined at section 9 of the Terms of Scheme)

 copies of any of the following – (i ) Plenary Summons and Statement of Claim (ii) Civil Bill or (ii i)

Personal Injury Summons in respect of legal proceedings commenced by the Applicant against

the State that concern the sexual abuse evidenced

 Supporting documentation and/or evidence setting out how the Applicant meets the real prospect

test (as outlined at sections 10 and 11 of the Terms of Scheme) including, where relevant, an

affidavit, statutory declaration or statement of truth

All applications should be emailed to stateclaims@ntma.ie (Ex Gratia Scheme should be referenced in

the subject line of all emails) or posted to:

Ex Gratia Scheme

State Claims Agency

Treasury Dock

North Wall Quay

Dublin 1

D01 A9T8