Application for the purchase of a TV Licence by …

1 Application for the purchase of a TV Licence by Direct Debit from a bank Current Account Part 1 of 2 TV Licence Details (* denotes mandatory fields) TV Licence Account Reference Number Full name on the TV Licence Only one name may be on the TV Licence * Full Address the TV Licence is to cover * CCOC Postal Address if different Contact Phone Number * TV Licence Holder Declaration I hereby agree to payment of my TV Licence by Direct Debit. I accept that it is my responsibility and undertake to ensure that my TV Licence remains valid at all times. Non-receipt of the full payment will result in the revocation of the TV Licence and a replacement TV Licence must be purchased in full or I may be prosecuted under the Broadcasting Act 2009. TV Licence Holder signature *_____ Date *_____ Terms & Conditions and Payment Option This Direct Debit Agreement will remain in force on a continuing year to year basis.

2 Any changes to the TV Licence fee will apply to all TV Licences purchased, or future TV Licence fees payable, after the date on which the fee comes into force. An Post will notify you, by post, on an annual basis of the amounts due to be debited from your bank Account. See Should you wish to change the frequency option for the payment of your next TV Licence , you must complete a new Application form and send it to your local TV Licence records office 16 days before your current TV Licence is due to expire. You may only cancel your direct debit instruction after full payment has been made and this agreement will continue to run on a year to year basis until cancelled. The TV Licence fee is payable on a year to year basis under the Broadcasting Act 2009 or under subsequent encompassing legislation. Under this Direct Debit Agreement, you are legally obliged to pay the full cost of the TV Licence .

3 You are legally required to continue paying for your TV Licence during its validity period regardless of whether you discard the TV Set, are awarded a Department of Social Protection TV Licence , leave the country or move to another premises already covered by a TV Licence or for any other circumstances. You are required to inform An Post TV Licences if you are changing the bank account number for the payment of the TV Licence . The onus is on the bank Account Holder to ensure the Direct Debit Instruction remains in operation for the payment of the TV Licence . The TV Licence fee may be paid by an annual debit or by instalments. Please tick the box indicating the frequency of direct debiting that you require, annually, bi-annually, quarterly or monthly. Where a direct debit mandate is being set-up in respect of a renewal TV Licence , the existing expiry date of the TV Licence will remain unchanged and any arrears due to the date of the set-up will be collected in the first instalment.

4 Tick Debit Frequency Annual Bi-annually Quarterly Monthly bank Account Holder Declaration I hereby instruct my bank to pay Direct Debits from my account at the request of An Post TV Licence . The amounts to be debited may be variable. I shall duly notify An Post TV Licence in writing if I wish to cancel this instruction but shall only do so upon completion of payment for the current TV Licence . I agree to the terms and conditions of paying the TV Licence fee by Direct Debit from my bank Current Account and I fully accept that this Direct Debit Agreement is legally binding. bank Account Holder signature * _____ Date *_____ Part 1 - Application for the purchase of a TV Licence and Part 2 - SEPA Direct Debit mandate form must be completed CHECKLIST: Have you completed all mandatory sections? (denoted by *) Have you signed both sides of the form?

5 Have you retained a copy of this Direct Debit Agreement for your reference? Please complete and return to your local TV Licence Records Office. See: - An Post TV Licence reserves the right to decline a Direct Debit mandate as a TV Licence payment option. Banks may refuse to accept instructions to pay Direct Debits from some types of bank accounts Information provided to An Post TV Licence is securely and safely held and processed by An Post TV Licence in accordance with relevant legislation, including the Data Protection Acts 1988-2003. Unique mandate ReferenceTVV(Unique mandate Reference will be created by TV Licence records office)Creditor IdentifierBank Account Holder Name: *(Name on Debtor's bank Account) bank Account Holder Address: *City/Post Code: *Country:* bank Account Holder's IBAN Number: * bank Account Holder Identifer Code - BIC / SWIFT:*Creditor Name:An Post TV LicenceCreditor Address:3B GPO, O'Connell StreetCity:Dublin 1 Country:IrelandType of Payment: Recurrent payment Date of signature:*DDMMYYYYS ignature(s):*(Authorised Signatories of bank Account Holder above)Block Capitals:*SEPA Direct Debit MandatePART 2 of 2IE48 ZZZ300450 Please complete all the fields below marked *Note.

6 Your rights regarding the above mandate are explained in a statement that you can obtain from your signing this mandate form, you authorise (A) An Post TV Licence to send instructions to your bank to debit your account and (B) your bank to debit your account in accordance with the instruction from An Post TV Licence . As part of your rights, you are entitled to a refund from your bank under the terms and conditions of your agreement with your bank . A refund must be claimed within 8 weeks starting from the date on which your account was debited. TVMandate Issue April 2016