[The third party is not a bank or building society.
the third party is
whose address in England and Wales is
4. Other persons’ interests
The persons (in addition to the judgment debtor) who have a claim to the money owed by the third
The following: (names and address(es))
Information known about each person’s claim:
5. Sources and grounds of information
The judgment creditor knowns or believes that the information in section 3 and 4 is correct because:
6. Other applications
In respect of the judgment debt,
the judgment creditor has made no other applications for third party debt orders.
the judgment creditor has already made the following application(s) for third party debt order:
Details of application(s)
Third party’s name
Statement of Truth
*I believe (the judgment creditor believes) that the facts stated in this application form are true.
*I am duly authorised by the judgment creditor to sign this statement
signed _________________________________ date __________________
*(Judgment creditor)(Litigation friend (where judgment creditor is a child or a patient))(Judgment creditor’s solicitor)
*delete as appropriate
Full name ___________________________________________________
Name of judgment creditor’s solicitor’s firm ______________________________________
position or office held ______________________________ (if signing on behalf of a firm or company)
Judgment creditor’s or if applicable
judgment creditor’s Ref. no.
solicitor’s address to fax no.
which documents DX no.
should be sent. e-mail