<p> Pyrite Resolution Board</p><p>Application Form for Appeals to the Board (as per Section 27 of the Pyrite Resolution Act 2013)</p><p>I am seeking to appeal the decision to (please tick as appropriate):</p><p> refuse an application for the Pyrite Remediation Scheme </p><p> exclude a dwelling from Pyrite Remediation Scheme </p><p>Date on which the notification of the decision was issued: (dd/mm/yyyy)</p><p>Application Reference Number:</p><p>Applicant’s Name: [Please complete the following in block capitals]</p><p>Applicant’s Address:</p><p>[Address to which any written communication will be sent]</p><p>Phone No.:</p><p>Email: [Address to which any electronic communication will be sent]</p><p>Address of dwelling (for which the application was made):</p><p>Page 1 of 4 Grounds for the Appeal:</p><p>Please state the reasons for the appeal. All details relevant to the appeal should be presented, including any additional information not provided in your application.</p><p>Note: Prior to completing this appeal, please refer to the procedures for hearing and determining appeals – located in the publications section of the Pyrite Resolution Board website or through the following link http://www.pyriteboard.ie/Publications.aspx .</p><p>The Board will not consider any supplementary documents, particulars or other information submitted by an applicant after expiry of the appeal period, other than additional material requested by the Board.</p><p>If necessary, appeal details can be continued or provided in full on a separate sheet.</p><p>Is an oral hearing of the appeal requested? Yes No</p><p>Page 2 of 4 Page 3 of 4 List of documents submitted:</p><p>List and number all documents submitted with your appeal. </p><p>Note: If the appeal is submitted online, all accompanying documents must be submitted in pdf format.</p><p>If necessary, the list of submissions with your appeal can be continued or provided in full on a separate sheet.</p><p>DECLARATION</p><p>I confirm that I wish to appeal the decision to refuse the application or exclude the dwelling from the scheme, to the Pyrite Resolution Board in accordance with Section 27 of the Pyrite Resolution Act 2013, on the grounds stated above.</p><p>I declare that the information provided by me is true, accurate and takes into consideration the provisions of the Pyrite Resolution Act 2013 and the Pyrite Remediation Scheme.</p><p>Applicant’s Signature</p><p>Date</p><p>It is an offence to furnish information that is false or misleading to the Board for the purpose of inclusion of a dwelling in the Scheme. A person guilty of such an offence may be liable to a fine, costs and expenses.</p><p>Page 4 of 4</p>