Complaints Board - Claim Form

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Complaints Board – Claim Form

1. Details of Complainant

In which capacity are you submitting this complaint*

Please select

Please select
Lawyer or Legal Representative
Club or Member Association
In my own capacity

First Name*

Surname*

ID Card No*

Tel/Mob*

Email*

Upload Proxy*

Drop files here or click to select

Client Name*

Client Email*

Client Tel/Mob*

Designation on behalf of the club*

Please select

Please select
President
Secretary
Teasurer
Vice-President
Asst. Secretary
Deputy Treasurer

Club Name:*

Club Email*

2. Details of Respondent

Complaint respondent type

Please select

Please select
Individual
Club
Member Association

Club/Member Name*

Respondent Name*

Respondent Surname*

Respondent ID Card No

Respondent Tel/Mob

Respondent Email

3. Claim request details

a.) Please insert below a detailed description of the claim request being made, including all required information in an accurate manner:

b.) Please insert below the total claim value in Euros

c.) Please insert below the details of any witnesses being presented or requested

Details to include Last Name, First Name, I.D. card No., Tel/Mob Number & E-mail address. Any written evidence submitted by witnesses should be listed here and included in the attachments in Section 3d.

Upload Documents

Drop files here or click to select

Any evidence or additional material can be uploaded here

d.) Please list below all the documents being attached to this complaint claim (if applicable):

4. Protest Deposit Fee

Payable Amount*

€25 for claims up to €2,500 or when the complaint has no monetary value
€100 for claims over €2500 and up to €10,000
€250 for claims over €10,000

Applicant Details

on behalf of

Payment Method (in my own capacity)*

Online Payment

Payment Method*

MFA Account (only applicable to clubs)

Online Payment

Signature*

I hereby declare, that the above details and documentation are true and correct

1. Details of Complainant

2. Details of Respondent

3. Claim request details

4. Protest Deposit Fee

Applicant Details

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