Ex Gratia Scheme Application Form

Published date21 July 2021
IssuerDepartment 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
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

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