Form Rf 134 – Fill Out and Use This PDF

The application is for the following replacement document(s) (please tick)

Is do athshol‡thar an doicimŽad (na ndoicimŽad) seo leanas Ž an t-iarratas (ticŽal le do thoil)

DÕUs‡id Oifige Amhain

(ii) Certificate of Roadworthiness Light

Heavy

D‡ta Faighte

Cine‡l T‡ille

MŽid na T‡ille

Eagr‡n

Sraithuimhir Admh‡la

Data Eisthe

15/4

Stampa

Oifige

I hereby declare that the document(s) ticked above in respect of Vehicle Registration Number (Index Mark if Trailer)

has been lost, destroyed, stolen or

The circumstances of the loss or destruction etc. are as follows:

I request that a replacement be issued to me on payment of the prescribed fee and I undertake to return the original to the Licensing Authority if it should subsequently come into my possession.

F—graim le seo go bfhuil an (na) doicimŽad(Žid) tice‡lta thuas maidir le Uimhir Chl‡rœch‡in Fheithicle (Comhartha Mas Leant—ir)

Caillte, sciosta, goidthe n—

Is mar leanas at‡ cœins’ caillteanais n— scriosta sri:

Iarraim go n-eiseofa’ athshol‡th‡r dom ar ’ocha’oocht na t‡ille ceaptha agus glacaim orm fŽin an bunerra a chur arais chuig an œdar‡s. Ceadœnaithe m‡ bh’onn sŽ I mo sheilbh ina dhiaidh sin.

Signed

Name (BLOCK LETTERS)

Address

Town/City

County

Date

Phone No.

Day Month Year

S’nithe

Ainm (CEANNLITHREACHA)

Seoladh

Baile/Cathair

Contae

D‡ta

Uimhir Ghuth‡in

L‡M’ Bliain

NB AN APPLICATION IS NOT COMPLETE UNTIL THE VERIFICATION BELOW IS COMPLETED

TO BE COMPLETED AT A GARDA STATION

The above-named reported the loss/destruction orof the document ticked above. I am satisfied, on the basis of the information available to the Gardai at this Station and the position as elaborated on by the applicant, that this appears to be a valid application. The applicant has been reminded that any person making a false declaration is liable to prosecution and on conviction to heavy penalties.

1. The completed Form must be sent to your local Motor Tax Office

NB Nil Iarratas L’onta Go mB’orun an Deimhniœ Th’os L’onta

Le L’onadh I St‡isiœn Garda’

Thuairiscigh an tŽ ainmithe thuas caillteanas / scrios n—an doicimŽid tice‡lta thuas. T‡im s‡sta de rŽir an eolais at‡ ar f‡il do na Garda’ ag an st‡isiœin seo agus na staide mar at‡ lŽirithe go moin ag an iarrts—ir gur cosœil gur iarratas bail’ Ž seo. Meabhra’odh don iarrtas—ir gur fŽidir aonduine a dhŽanann r‡iteas brŽagacg a chœisiœ agus m‡ cionta’tear Ž is fŽidir tromphion—s a chur air.