If you are paying by direct debit, this
will be the account charged.
This is the address to which we will
normally send requisitions. However
if you insert an email address, we will
use this whenever possible. Where
an application is lodged by e-DRS all
documents and correspondence will
be dealt with electronically.
This application is sent to Land Registry by
Key number (if applicable):
Address or UK DX box number:
You may give up to three addresses
for service, one of which must be a
postal address whether or not in the
UK (including the postcode, if any).
The others can be any combination
of a postal address, a UK DX box
number or an electronic address.
Address(es) for service of the applicant. The address(es) will be
entered in the register and used for correspondence and the
service of notice:
Place 'X' in the appropriate box and
complete the relevant statement.
If you are a conveyancer the
certificate is sufficient to comply with
Land Registry’s requirements. If no
conveyancer is acting, you must
enclose a certified copy of the order
with this application. Land Registry
may destroy documents after
I enclose an office copy of the order dated:
I am the applicant’s conveyancer and certify that I am holding
an official copy of the order dated made under
section 33(5) of the Family Law Act 1996 by
Enter date of order.
Enter date of registration.
Following an order dated and made under
section 33(5) of the Family Law Act 1996, I apply under section 32
of, and paragraph 4(3)(a) of Schedule 4 to, that Act for the
renewal, by way of agreed notice, of the registration of the
[notice][caution against dealings] registered on
against the title number(s) shown in panel 2.
If a conveyancer is acting for the
applicant, that conveyancer must
sign. If no conveyancer is acting, the
applicant must sign.
Signature of applicant
or their conveyancer:
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.
Under section 66 of the Land Registration Act 2002 most documents (including this form) kept by the registrar relating to an
application to the registrar or referred to in the register are open to public inspection and copying. If you believe a document
contains prejudicial information, you may apply for that part of the document to be made exempt using Form EX1, under rule 136
of the Land Registration Rules 2003.
© Crown copyright (ref: LR/HO) 06/14