Notice of Appeal

Notice of appeal
against a decision of the Criminal Injuries Compensation Authority,

Alexander Bain House, Atlantic Quay, 15 York Street, Glasgow G2 8JQ
Your completed Notice of appeal must be received by the Tribunal no later

than 90 days after the date on the Authority’s 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.
T210 Notice of Appeal, against a decision of the Criminal Injuries Compensation Authority (09.22)
Page 1
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 12
No. Go to question 13
8. Title
Mr Mrs Ms
Miss Dr Other
9. Name
10. Address - if appealing on behalf of a minor
Postcode
11. Date of birth
12. Email address
13. Do you require an interpreter?

Yes. I require an interpreter.
Language
Dialect
No
Page 2
Representation
14. Do you have a representative? Q. 14 – If you have
a representative all
Yes. Go to question 15
documents will be sent to
No. Go to question 22 your representative, not to
you. This will continue until
15. Is your representative legally qualified? you (or your representative)
tell the tribunal in writing
Yes, your representative must sign this form
that your representative no
No, you must sign this form longer acts for you.
16. Name
17. Address
Postcode
18. DX no. - if applicable
19. Representative’s reference number
20. Representative’s phone number
21. Representative’s email address
Page 3
Reasons for appealing
22. What are your grounds for appealing against the
Q.22 – If you do not provide
Authority’s Review Decision?
this information your appeal
Give all details you want to be taken into account will not be admitted.
If you need more space

continue on a separate
sheet and attach it to this
form.
Page 4
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.
23. Are you applying for an extension of time to lodge your appeal?
Yes, my reasons for applying for an extension of time is
No
24. Has an extension been previously granted to submit this form?
Yes
No
Page 5
Supporting documents
You must send a copy of the Authority’s Review decision letter with
this notice
25. Are there any documents you currently do not possess 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?
26. Please list any additional documents and information you are Q.26 – If further evidence
enclosing (other than the Authority’s decision letter) in the box below. is not available at this time,
please do not hesitate
to submit this form.
Additional evidence may
be submitted at a later
date.
Page 6
Additional information
27. What is the name of the Police Authority dealing with the incident?
28. Crime Reference number (if known)
29. Date of incident
30. Incident location
31. Linked Claims lodged with the Criminal Injuries Compensation Authority
32. Do you have any other ongoing compensation claims such as a

civil claim?
Yes
No
33. Do you consent to a short notice hearing, for example less than
14 days notice?
Yes
No
Signature
If you have a legally qualified representative they must sign this form.
If they are not legally qualified you must sign the form.
Signature
Date
Page 7
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
or
CIC.enquiries@justice.gov.uk
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.
Page 8

Notice of Appeal

Uploaded by

Document Information

Original Description:

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Notice of Appeal

Uploaded by

Copyright:

Available Formats

Notice of appeal

against a decision of the Criminal Injuries Compensation Authority,

Your completed Notice of appeal must be received by the Tribunal no later

Full reference no.

Date of review decision being appealed

5. National insurance number

6. Daytime phone number

10. Address - if appealing on behalf of a minor

11. Date of birth

12. Email address

13. Do you require an interpreter?

18. DX no. - if applicable

19. Representative’s reference number

20. Representative’s phone number

21. Representative’s email address

If you need more space

Yes, my reasons for applying for an extension of time is

Yes. Please list these documents in the table below

Title of document When do you expect

28. Crime Reference number (if known)

29. Date of incident

30. Incident location

32. Do you have any other ongoing compensation claims such as a

HM Courts & Tribunals Service

You might also like