This form should be accompanied by Form EX1.
Any parts of the form that are not typed should be completed in black ink and in block capitals.
This form is exempt from the general rights of inspection and copying. However, Form EX1 and any
accompanying correspondence are not exempt.
If you need more room than is provided for in a panel, and your software allows, you can expand any panel in the
form. Alternatively use continuation sheet CS and attach it to this form.
Conveyancer is a term used in this form. It is defined in rule 217A, Land Registration Rules 2003 and includes
persons authorised under the Legal Services Act 2007 to provide reserved legal services relating to land
registration and includes solicitors and licensed conveyancers.
For information on how HM Land Registry processes your personal information, see our Personal Information
Charter.
Leave blank if this application
accompanies an application for first
registration.
1
Title number(s) of the registered estate(s) to which the document
relates:
Insert address including postcode (if
any) or other description of the
property, for example ‘land adjoining
2 Acacia Avenue’.
2
Property:
The information in panels 3 and 4 will
help us if forms EX1 and EX1A
become detached.
Provide the full name(s) of the
person(s) applying to exempt the
document. Where a conveyancer
lodges the application, this must be
the name(s) of the client(s), not the
conveyancer.
3
Enter the name of the applicant on the accompanying EX1:
This panel must always be
completed.
A key number is only available to
professional customers, such as
solicitors.
This is the address to which we will
normally send requisitions. However
if you insert an email address, we will
use this whenever possible.
4
The EX1 application is sent to Land Registry by
Name:
Address or UK DX box number:
Email address:
Reference:
Phone no:
Fax no:
'Prejudicial information' means
(a) information that relates to an
individual who is the applicant under
rule 136 and if disclosed to other
persons (whether to the public
generally or specific persons) would,
or would be likely to, cause
substantial unwarranted damage or
substantial unwarranted distress to
the applicant or another, or
(b) information that if disclosed to
other persons (whether to the public
generally or specific persons) would,
or would be likely to, prejudice the
commercial interests of the applicant
under rule 136.
Warning: Have you checked to make
sure that the prejudicial information
does not appear in any other
document which may be open to
inspection?
5
State why you believe that the information contained in the
document referred to on the accompanying Form EX1 is
prejudicial information defined in rule 131 of the Land Registration
Rules 2003:
If a conveyancer is acting for the
applicant, that conveyancer must
sign. If no conveyancer is acting, the
applicant (and if more than one
person then each of them) must sign.
6
Signature of applicant
or their conveyancer:
Date:
WARNING
If you dishonestly enter information or make a statement that you know is, or might be, untrue or misleading, and intend by doing
so to make a gain for yourself or another person, or to cause loss or the risk of loss to another person, you may commit the
offence of fraud under section 1 of the Fraud Act 2006, the maximum penalty for which is 10 years’ imprisonment or an unlimited
fine, or both.
Failure to complete this form with proper care may result in a loss of protection under the Land Registration Act 2002 if, as a
result, a mistake is made in the register.
© Crown copyright (ref: LR/HO) 05/18
click to sign
signature
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