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                                          CAPITAL ACQUISITIONS TAX (Form A3C)

                         Affidavit to be used where an application is made for a second or subsequent grant of
                        representation (except where the Estate was within the operation of the previous grant,
                         in which case the appropriate form of affidavit as for an original grant should be used)
                                   Please complete this form in BLOCK CAPITALS using BLUE INK
                                                        All fields are mandatory

 PPS No. of
 deceased
 Details of Person/Solicitor to be contacted in event of Enquiry regarding this Affidavit
 Forename

 Surname

 Address




 Telephone No.                                                                                     DX Number (if applicable)

 Contact e-mail

 Agent's
 Reference                                                                                                         TAIN                         -
 The High Court
 High Court Probate Office/District
 Probate Registry at
 This Affidavit in duplicate and Original Grant of Representation in the Estate of the Deceased Person herein together with all appropriate Probate
Part 2 Details of theaapplicants Grant (Second Grant) must be delivered to the appropriate Probate Office/Registry.
 documentation to obtain De Bonis Non

 Details of the applicant(s)
 I/We, the Applicant(s)
 Forename of
 1st Applicant
 Surname of
 1st Applicant
 Address




 Occupation

 Relationship to deceased

 Forename of
 2nd Applicant
 Surname of
 2nd Applicant
 Address




 Occupation

 Relationship to deceased


        A3C                                                             Page 1                                                 3619200999
Details of the applicant(s) (cont.)
Forename of
3rd Applicant
Surname of
3rd Applicant
Address




Occupation

Relationship to deceased


Forename of
4th Applicant
Surname of
4th Applicant
Address




Occupation

Relationship to deceased




desire to obtain a grant of
(Insert here 'Double Probate of the Will' or 'Administration with Will Annexed of the Unadministered Estate' or 'Administration of the Unadministered
Estate' or as the case may be:-


Details of Deceased Person herein

in the Estate of
Forename of
deceased
Surname of
deceased
Address of
deceased




                    D   D       M   M       Y   Y   Y   Y
Date of
death                       /           /
Place of
death



Domicile at death
(Country/State)




           A3C                                                           Page 2                                                 2706200995
                                    All considerations to be stated in whole EURO only. Do not enter Cent

Property in State remaining unadministered in estate of deceased
Please complete the following questions as relevant to this estate:
1. What assets remain unadministered since the original grant has issued?

                                     Millions           Thousands       Hundreds       Details of
                                                                                       Unadministered
Personal Property
                                                    ,               ,                  Personal
                                                                                       Property



Real Property
                                                    ,               ,
Gross Irish Estate
                                                    ,               ,
Debts due and unpaid
                                                    ,               ,
Net value of Irish Estate
                                                    ,               ,
Please enter full details of immoveable property on page 6 herein

2. Why is a fresh grant required?



3. Place        in the appropriate box if the original personal representative is deceased              Yes          No

If the answer is yes please state:

                        D   D        M    M             Y   Y   Y   Y
Date of
death                           /               /
                        D   D        M    M             Y   Y   Y   Y
Date of grant of
representation                  /               /
Place of issue of grant
of representation
The account on this form is a true account of the particulars and value, at the date of this Affidavit, in so far as I have been able to ascertain the same,
of all the UNADMINISTERED property of the deceased within the operation of the previous grant, whether in possession or reversion, within the State,
exclusive of what the Deceased may have been possessed of or entitled to as a trustee and not beneficially, but including property over which the
Deceased had and exercised a general power of appointment.




          A3C                                                                      Page 3                                          6705200998
Sworn by

Forename of 1st Applicant

Surname of 1st Applicant

At

On the                           day of                                                        Signature of Applicant/Deponent

Before me, a Commissioner for Oaths/Practising Solicitor/Court Clerk
and
(Tick relevant box and Delete as appropriate)
(i) the Deponent (Applicant) is personally known to me
or
(ii) the Deponent (Applicant) has been identified to me by
     who is personally known to me

Identifier's Signature
I certify that I know the Deponent/Applicant
or
(iii) the identity of the Deponent has been established by reference to a relevant document containing a photograph

Document Type:                                                                     Issue No:


Signature Commissioner for Oaths/Practising Solicitor/Court Clerk




Forename of 2nd Applicant

Surname of 2nd Applicant


At

On the                           day of                                                        Signature of Applicant/Deponent

Before me, a Commissioner for Oaths/Practising Solicitor/Court Clerk
and
(Tick relevant box and Delete as appropriate)
(i) the Deponent (Applicant) is personally known to me
or
(ii) the Deponent (Applicant) has been identified to me by
     who is personally known to me

Identifier's Signature
I certify that I know the Deponent/Applicant
or
(iii) the identity of the Deponent has been established by reference to a relevant document containing a photograph

Document Type:                                                                     Issue No:


Signature Commissioner for Oaths/Practising Solicitor/Court Clerk




 WARNING: IF THE APPLICANT(S) SWEAR TO THIS AFFIDAVIT WITHOUT PERSONALLY VERIFYING THAT THE STATEMENTS IN IT ARE
 TRUE, THEY MAY MAKE THEMSELVES LIABLE TO PENALTIES.


         A3C                                                           Page 4                                              1326200992
Forename of 3rd Applicant

Surname of 3rd Applicant

At

On the                           day of                                                        Signature of Applicant/Deponent
Before me, a Commissioner for Oaths/Practising Solicitor/Court Clerk
and
(Tick relevant box and Delete as appropriate)
(i) the Deponent (Applicant) is personally known to me
or
(ii) the Deponent (Applicant) has been identified to me by
     who is personally known to me

Identifier's Signature
I certify that I know the Deponent/Applicant
or
(iii) the identity of the Deponent has been established by reference to a relevant document containing a photograph

Document Type:                                                                     Issue No:


Signature Commissioner for Oaths/Practising Solicitor/Court Clerk




Forename of 4th Applicant

Surname of 4th Applicant



At

On the                           day of                                                        Signature of Applicant/Deponent
Before me, a Commissioner for Oaths/Practising Solicitor/Court Clerk
and
(Tick relevant box and Delete as appropriate)
(i) the Deponent (Applicant) is personally known to me
or
(ii) the Deponent (Applicant) has been identified to me by
     who is personally known to me

Identifier's Signature
I certify that I know the Deponent/Applicant
or
(iii) the identity of the Deponent has been established by reference to a relevant document containing a photograph

Document Type:                                                                     Issue No:


Signature Commissioner for Oaths/Practising Solicitor/Court Clerk




 WARNING: IF THE APPLICANT(S) SWEAR TO THIS AFFIDAVIT WITHOUT PERSONALLY VERIFYING THAT THE STATEMENTS IN IT ARE
 TRUE, THEY MAY MAKE THEMSELVES LIABLE TO PENALTIES.


         A3C                                                           Page 5                                              5108200994
                                     All considerations to be stated in whole EURO only. Do not enter Cent

Schedule of lands and buildings
                                                                                                                          Place       in the appropriate box
                                                                   Milk Quota                                                         Yes                     No
Is there a super levy milk quota attached to any of the property described below

Enter the property number to which this relates

Litres

Is the estimated value supported by a professional valuation


                                                                      Timber
Is any of the property described below agricultural property which consists of trees or underwood

If so, identify clearly the lands involved by entering
the property number to which this relates
The value of the lands should include the value of the trees and underwood

Property 1

                                                                          Lands                                   Buildings
SITUATION OF PROPERTY                                                    Place
                                                                         Place      in the appropriate box        Place        in the appropriate box

County:                                                                      Agricultural      Commercial          Residential                   Office
City:
                                                                         Development                    Mix       Commercial              Agricultural
Town:
Townland or
                                                                             Residential        Single Site               Retail                   Mix
Street and No.
Electoral Division or
Ward                                                                                                                  Industrial
                                                                                                                  Date of lease
                                                                                                                  D   D         M    M       Y     Y      Y   Y

                    Estimated market                                                                                       /             /
         Millions
                    value of property
                         Thousands       Hundreds
                                                                                            Leasehold
                                                                                                              {   Length of Term
                                                                                                                  Y Y Y          M M

                     ,               ,                             Tenure                                                        -
                                                                                                                  If registered, folio number
                                                                                            Freehold



Property 2

                                                                          Lands                                   Buildings
SITUATION OF PROPERTY                                                    Place
                                                                         Place      in the appropriate box        Place        in the appropriate box

County:                                                                      Agricultural      Commercial          Residential                   Office
City:
                                                                         Development                    Mix       Commercial              Agricultural
Town:
Townland or
                                                                             Residential        Single Site               Retail                   Mix
Street and No.
Electoral Division or
Ward                                                                                                                  Industrial
                                                                                                                  Date of lease
                                                                                                                  D   D         M    M       Y     Y      Y   Y

                    Estimated market                                                                                       /             /
         Millions
                    value of property
                         Thousands       Hundreds
                                                                                            Leasehold
                                                                                                              {   Length of Term
                                                                                                                  Y Y Y          M M

                     ,               ,                             Tenure                                                        -
                                                                                                                  If registered, folio number
                                                                                            Freehold



         A3C                                                            Page 6                                                       5950200999
                                    All considerations to be stated in whole EURO only. Do not enter Cent

Property 3
                                                                      Lands                                 Buildings
SITUATION OF PROPERTY                                                Place
                                                                     Place    in the appropriate box        Place        in the appropriate box

County:                                                                Agricultural      Commercial          Residential                   Office
City:
                                                                      Development                 Mix       Commercial              Agricultural
Town:
Townland or
                                                                       Residential        Single Site               Retail                   Mix
Street and No.
Electoral Division or
Ward                                                                                                            Industrial
                                                                                                            Date of lease
                                                                                                            D   D         M    M       Y     Y      Y   Y

                   Estimated market                                                                                  /             /
        Millions
                   value of property
                        Thousands       Hundreds
                                                                                      Leasehold
                                                                                                        {   Length of Term
                                                                                                            Y Y Y          M M

                    ,               ,                            Tenure                                                    -
                                                                                                            If registered, folio number
                                                                                      Freehold

Property 4
                                                                      Lands                                 Buildings
SITUATION OF PROPERTY                                                Place
                                                                     Place    in the appropriate box        Place        in the appropriate box

County:                                                                Agricultural      Commercial          Residential                   Office
City:
                                                                      Development                 Mix       Commercial              Agricultural
Town:
Townland or
                                                                       Residential        Single Site               Retail                   Mix
Street and No.
Electoral Division or
Ward                                                                                                            Industrial
                                                                                                            Date of lease
                                                                                                            D   D         M    M       Y     Y      Y   Y

                   Estimated market                                                                                  /             /
        Millions
                   value of property
                        Thousands       Hundreds
                                                                                      Leasehold
                                                                                                        {   Length of Term
                                                                                                            Y Y Y          M M

                    ,               ,                            Tenure                                                    -
                                                                                                            If registered, folio number
                                                                                      Freehold

Property 5

                                                                      Lands                                 Buildings
SITUATION OF PROPERTY                                                Place
                                                                     Place    in the appropriate box        Place        in the appropriate box

County:                                                                Agricultural      Commercial          Residential                   Office
City:
                                                                      Development                 Mix       Commercial              Agricultural
Town:
Townland or
                                                                       Residential        Single Site               Retail                   Mix
Street and No.
Electoral Division or
Ward                                                                                                            Industrial
                                                                                                            Date of lease
                                                                                                            D   D         M    M       Y     Y      Y   Y

                   Estimated market                                                                                  /             /
        Millions
                   value of property
                        Thousands       Hundreds
                                                                                      Leasehold
                                                                                                        {   Length of Term
                                                                                                            Y Y Y          M M

                    ,               ,                            Tenure                                                    -
                                                                                                            If registered, folio number
                                                                                      Freehold

        A3C                                                         Page 7                                                     0654200995

				
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