Page 1
Notice of appeal
against a decision of the Criminal Injuries Compensation Authority,
Alexander Bain House, Atlantic Quay, 15 York Street, Glasgow G2 8JQ
T210 Notice of Appeal, against a decision of the Criminal Injuries Compensation Authority (04.19)
Your completed Notice of appeal must be received by the Tribunal no later
than 90 days after the date on the Authoritys Review Decision letter.
Full reference no.
Date of review decision being appealed
About you
1. Your title
Mr Mrs Ms
Miss Dr Other
2.
Name
3. Address
Postcode
4. Date of birth
5. National insurance number
6. Daytime phone number
Q.6 – A phone number
will help us to contact you
quickly if needed.
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7. Are you appealing on behalf of someone else?
Yes, I’m appealing on behalf of
a minor, go to question 8
Fatal, go to question 8
No, go to question 12
8.
Title
Mr Mrs Ms
Miss Dr Other
9.
Name
10. Address - if appealing on behalf of a minor
Postcode
11. Date of birth
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Representation
12. Do you have a representative?
Yes, go to question 13
No, go to question 19
13.
Is your representative legally qualied?
Yes, your representative must sign this form
No, you must sign this form
14.
Name
15. Address
Postcode
16. DX no. - if applicable
17. Representatives reference number
18. Representatives phone number
Q. 12 – If you have
a representative all
documents will be sent to
your representative, not to
you. This will continue until
you (or your representative)
tell the Tribunal in writing
that your representative no
longer acts for you.
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Reasons for appealing
19. What are your grounds for appealing against the
Authoritys Review Decision?
Give all details you want to be taken into account
Q.19 – If you do not provide
this information your appeal
will not be admitted.
If you need more space
continue on a separate
sheet and attach it to this
form.
Page 5
Request for an extension of time
We may consider an extension to the 90 day limit, whether your
application is made within or outside of the period of 90 days, if it is based
on good reasons and it would be fair to do so.
Example: If you are waiting for further medical reports which you must see
before you decide whether or not to make an appeal.
20.
Are you applying for an extension of time to lodge your appeal?
Yes, my reasons for applying for an extension of time is
No
21.
Has an extension has been previously granted to submit this form?
Yes
No
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Supporting documents
You must send a copy of the Authority’s Review decision letter with
this notice
22.
Are there any documents you currently do not posses but wish to
supply and rely on in support of your appeal?
Yes, please list these documents in the table below
No
Title of document When do you expect
to supply it?
23.
Please list any additional documents and information you are
enclosing (other than the Authoritys decision letter) in the box below.
Q.23
If further evidence is
not available at this time,
please do not hesitate
to submit this form.
Additional evidence may
be submitted at a later
date.
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Additional information
24. What is the name of the Police Authority dealing with the incident?
25. Crime Reference no. (if known)
26. Date of incident
27. Incident location
28. Linked Claims lodged with The Criminal Injuries Compensation Authority
29. Do you have any other ongoing compensation claims such as a
civil claim?
Yes
No
Signature
If you have a legally qualied representative they must sign this form.
If they are not legally qualied you must sign the form.
Signature
Date
Reset form
Print form
Reset form
Print form
Page 8
Where to send your completed form
You must now send a signed copy of this form to:
HM Courts & Tribunals Service
Glasgow Tribunals Centre
20 York Street
Glasgow G2 8GT
or
DX 551940 Glasgow 42
Alternatively you can fax a signed copy of this form to: 08707 394168.
You must then send a copy of the form and any documents in support
to arrive within 7 days.
The Ministry of Justice and HM Courts and Tribunals Service processes personal information
about you in the context of tribunal proceedings. For details of the standards we follow
when processing your data, please visit the following address www.gov.uk/government/
organisations/hm-courts-and-tribunals-service/about/personal-information-charter
To receive a paper copy of this privacy notice, please call 0300 790 6234.
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