Plné znění - 241/2006 Sb.

Questionnaire xxx xxx Assessment xx Applications xxx xxx Xxxxxxxxx xx Xxxxxxxxx Support to Xxxxxxx xx Criminal Xxxx xxxxxxxx xx Xxx Xx. 209/1997 Xxxx., xx xxx xxxxxxxxx of xxxxxxxxx xxxxxxx xx xxx xxxxxxx xx criminal xxxx xxx on xxxxxxxx xxxxxxx other xxxx, xx amended

Dear Xxx/Xxxxx,

Xx xxxxxxxxx xxx xxxxxxxxx you xxxx xxxxxxxx questions in xxxx xxxxxxx situation. Xxxxxxx, filling in xxxx questionnaire xx xxxxxxxx xxx xxx xxxxx xxxxxxxxxx xx xxxx xxxxxxxxxxx for xxx provision of xxxxxxxxx xxxxxxx xxxxxxxx xx Act xx. 209/1997. Xxxxx you xxx your cooperation; xx xx highly xxxxxxxxxxx.

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X. Xxxxxx xxxxxxx xxxx xx xxx xxxxxxxx xxxx xx xxx applicant - x.x. xxx victim xx the xxxxxxxx xxx xxx xxx xxxxxxxx xxxxxx xxxx, xx the xxxxxxxx xx x xxxxxx xxx has xxxx xx xxxxxxxxxxx of xxx xxxxxxxx act:

1. Xxxxxxx:

2. Xxxxx name:

3. Xxxx of xxxxx:

4. Xxxxxxxxx xxxxxxx:

5. Xxxx xxxxxxxx xxxxxxx (xxxxxx xx diffen xxxx xxx xxxxxxxxx xxxxxxx, xxxx):

6. Phone Number:

7. X-xxxx xxxxxxx:

8. Nationality:

II. Xx xxx xxxxxxxxx xx xxxxxxxxxxx xx xxxxxxx xxxxxx ("xxxxxxxxxxxxxx") xx xxx xxxxx xx xxxxxxxxx xxxxxxxxxxxxxx (xxx xxxxxxxx, x xxxxx xxxxx xxxxxxxxxxx xx xxx/xxx parent) xx xx the xxxxx of x xxxxx xx xxxxxxxx, xxxxxx fill xx xxx xxxx of xxxx xxxxxxxxxxxxxx:

1. Xxxxxxx:

2. Xxxxx name:

3. Xxxxxxxxx xx xxxxxxxxxx xxxxxxx:

Xx xxx xxxxxxxxxxxxxx xx xxxxxx xxx xxxxxxxxxxx xx behalf xx xxx xxxxxxxxx, xxxxxx xxxx submit a xxxxxxxx xxxxxxxxxxx him/her xx xxxxxxxxx the xxxxxxxxx - x xxxx xx x xxxxx xx attorney (xxx contractual xxxxxxxxxxxxxx) xx a xxxx xx the xxxxx xxxxxxxxxxx (xxx statutory xxxxxxxxxxxxxx) or any xxxxx xxxxxxxxxx xxxxxxxx.

XXX. Xx xxx applicant xx x xxxxxxxx xx x person xxx xxx died xx xxxxxxxxxxx of xxx xxxxxxxxxx xxxxxxxx xxx, xxxxxx xxxx xx xxx personal xxxx xx xxx xxxxxxxx:

1. Xxxxxxx:

2. Given xxxx:

3. Date xx xxxxx:

4. Xxxx xx xxxxx:

5. Xxxx xxxxxxxxx xxxxxxx:

6. Nationality:

7. Relationship xx xxx xxxxxxxx xx xxx xxxxxxxxx (x.x. xxxxxx, daughter, xx individual xxxxxx xx common household)

If xxx applicant xx x xxxxxxxx xx x xxxxxx xxx xxxx xx xxxxxxxxxxx xx xxx criminal xxx, xxxxxx xxxxxx x copy xx xxx death certificate xxx any xxxxxxxxx xxxxxxx xxxx xxx xxxxxxxx supported xx xxx xx obligation xx xxxxxxx xxx xxxxxxxx (in xxx xxxx xx x xxxxxx-xxxxx relationship, xxxx xxxxxxxxx xxxxxxx xxxxx xxxxxxxxxxxx xx x xxxxx xxxxxxxx on xxx xxxxxxxxxx xx xxxxxxx xxx xxxxxxxxx; xx the xxxx xx married couples, xxxxxx xxxxxx x xxxxxxxx certificate).

Xxxxxx xxxxxxx the xxxx xx which xxx xxxxx was xxxxxxxxx and, xx xxx xxxxxx learned xxxxx xxx xxxxxxxxxxxx xx the crime xx x xxxxx xxxx, xxxxxx xxxx xxxxxxx the xxxx xxx the xxxxxx xx xxxxx xxx xxxxxx xxxxxxx xx xxxx consequences (e.g., xxx xxxx xx xxx medical xxxxxx).

XX. Xxxxxx specify xxx xxxxxxxx justice authority (x.x. xxxxxx, xxxxxx xxxxxxxxxx'x xxxxxx, xxxxx) xxxxx xxxx xxxxxxxx xxxxxxxxx xxxxxxxx xxxxxxxxxxx. Xxxxx xxx xxxxxxxxx xxxxxx of xxx xxxx related xx xxx respective xxxxxxxxxxx.

Xx xxxxxxxxx, please attach xxx latest xxxxxxxx xx the abovementioned xxxxxxxx xxxxxxx xxxxxxxxx xxxxx xxxxx xxxxxxxx xxx stage of xxx xxxxxxxxxx proceedings (x.x. resolution on xxx xxxxxxxxxxxxxxx xx xxxxxxxx prosecution, xxxx xx the xxxxxxxxxx, xxxxxxxxx - xxxxx xx xxxxxxxxx).

According xx xxx xxxxxxxxxx xx §8 xx Xxx no. 209/1997, xxx xxxxxx of xxxxxxxxx xxxxxxx xxx xx xxxxxxx or xxxxxxxx xxxxxxxxx xx xxxxxxx xxx xxxxxx xxx xxxx use xx all legal xxxxxxxx to xxxxxxx x xxxxx xxx xxxxxxxxxxxx xxxxxxx xxx xxxxxxxx xx xxx xxxxx person xxxxxxxxxxx xxx the xxxx xxxxxxxx. Do not xxxx xx xxxx xxxx if the xxxxxxxx xxx xxx xxxx identified.

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Fill xx xxxx VlIl xx xxx xxxxxxxxx xx x xxxxxxxx of xx individual who xxx xxxx xx xxxxxxxxxxx xx xxx xxxxxxxxx crime.

1. Xxx xxx x xxxxx, spouse xx xxxxx of the xxxxxx xxx died xx xxxxxxxxxxx xx xxx criminal xxxxxxx?

2. Xxx xxx xxxx xx x xxxxxx xxxxxxxxx xxxx xxx xxxxxxxx xxxxxx xxxxx xx the commitment xx the xxxxx?

3. Xxxx xxx x xxxxxxxxx xx xxx xxxxxx xx was xxx deceased obliged xx xxxxxxx xxx?

4. Xx xxx xxxxx xxxxxxx xxxx xxx xxxxxxxxxx described xx xxxxxxx 1 to 3? Xxxxxx xxxx xxxxx number, if xxxxx to xxx.

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Xxxxxxxxx xx xxx xxxxxxxxxx xx §2, xxxxxxx 2 of Xxx xx. 209/1997, x xxxxxx xxx xx x xxxxxxxx xx x xxxxxx who xxxx xx xxxxxxxxxxx xx x xxxxxxxx xxx xx xxxxxxxxxx xx xx x xxxxxx xx xx xx she xx x parent, xxxxxx xx xxxxx xx xxx xxxxxxxx xxx xxxxx xxxx xxx xx xxx in xxx xxxx xxxxxxxxx xx xx xxx xxxxxx xxx a xxxxxxxxx xx the xxxxxxxx xx the xxxxxxxx xxx xxxxxxxx xx support xxx xxxxxx.

Xx xxx xxxxxxxxx xx xxx victim xx a crime xxx xxx xxxxxxxx xxxxxx harm, please xxxx in xxxxx XX - XIV.

Xxxxxx attach x xxxxx-xxxxx assessment xx xxxx xxx xxxxxxxxx pursuant to Xxxxxx No. 440/2001 Xxxx. The respective xxxxxxxx should be xxxxxxxx from the xxxxxxxxx xxxxxxxxxxx xxx xxx victim's treatment. Xxxx xxxxxxx xxxxxx xxxx xxxxxxx a xxxxx-xxxxx xxxxxxxxxx of xxx pam suffered xxx a point-based xxxxxxxxxx of xxx xxxxxxxx xx xxx xxxxxx'x xxxxxx xxxxxxxx. Xxxxxx xxxx xx xxxx that xxxx xxx point-based xxxxxxxxxx xx xxx xxx xxxxxxxx xx xxxxxxxx xxx xxx xxxxxxxx xx Xxx no. 209/1997. According to xxx xxxxxxxxxx of §6, xxxxxxx 2 xx Xxx xx. 209/1997, xx xxxxxxxxx xxxxxxx xxxx xx xxxxxxxx unless xxx xxxxx xxxxxxxxxx xx xxx xxxx suffered xx xx xxxxx 100 xxxxxx.

Xxx xxxxxx may xxxxxx xxxx xxx financial xxxxxxx in xxx xxxxxx xx CZK 25,000 or xx xxxxxx equal xx xxx proved xxxxx xx xxxxxxx xxxxxxxxx xxx xxxx income (§7, xxxxxxx 1, xxxxxx a xx Xxx Xx. 209/1997 Xxxx.). lf xxx xxxxxx to apply xxx x xxxx xxx xxxxxxx, xxxxx xx xx need xx fill xx xxxxx XXX - XxX.

This xxxxxxxx xxx xxxxxxxx xxx xxxxxxxxxx, xxxxxxxx xxxxxxxxx, xxxxxxxxxxxxxx costs, xxxxxx xx assistant to xxxx out xx xxx xxxx or xxxx medical treatment, xxxxxxxxx xxxxxxxxxxxxxx xxxxx xxx., xxxxxxxx xxxx xxxxx have xxx xxxx xxxx xx xx xxxxxxxxx xxxxxxx. xx xxxx xxxxxxxx xxx xxx proved xx documentary xxxxxxxx, xxx Ministry xx Xxxxxxx may not xxxx them xxxx xxxxxxxxxxxxx.

Xxxxxx xxxxxx xxx xxxxxxxxx xxxxxxxxxx xxxx xxxxx xx xxx xxxxxxxxxxx.

Xx the xxxxxxxxx is an xxxxxxxx, xxxxx documents xxxxx xxxxxxx x xxxxxxxxx xxxx his/her xxxxxxxx xxxxxxxxxx the xxxxxxx salary xxxxxxxxx xx §351 xx. xxx. of Xxx xx. 262/2006, xxx Xxxxx Labour Xxxx, xx xxxxxxx. xx xxx xxxxxxxxx xx xxxx-xxxxxxxx, xxxx xxxxxxxx xxxxx be a xxxx xx xxx/xxx xxxx recent xxx xxxxxx. xx xxx xxxxxxxxx xx x xxxxxxx xxxxxx who xx xxxx xx xxxxx xxx/xxx impaired xxxxxx xxxxxxxx, please xxxxxx x document xxxxxxxxxx xxx xxxxxx xx xxx xxxxxxxxxx xxxxxxx. xx for xxx xxxxxx xxx xxxxxxxxx'x income xxxxxxxxx xxxxxx be xxxxxx, xx xxxxxxxxxxx cases xx xxxxxxxxx xxx xx xxxxxxxx.

Xx xxxxxx standing xxx xxxx xxxxxxxx xx x result of xxx xxxxxxxx act xx xxxxx I xxx a xxxxxx. X have xxx xxx xxxx xxxxxxxxxxx xxx the xxxx 1 have suffered xx x xxxxxx xx the criminal xxx.

X hereby xxxxxx xxxx I have xxx lodged xxx xxxxx for financial xxxxxxx or any xxxxxxx xxxxx xxx xxxxxxxxxxxx xxx the xxxx xxxxxxxx as x xxxxxx xx xxx xxxxxxxx xxx xx any xxxxxxx xxxxx xxxx the Xxxxx Xxxxxxxx.

X acknowledge xxxx according xx §12 xx Xxx Xx. 209/1997 Coll., xx xxx xxxxxxxxx xx financial xxxxxxx xxx xxx xxxxxxx xx xxxxxxxx xxxx xxx xx xxxxxxxx xxxxxxx other xxxx, xx xxxxxxx, X xx xxxxxxx to xxxxxxxxx xxx Xxxxxxxx xx Justice xxx xxxxxx received xx xxxxxxxxxxxx for xxx xxxx suffered, xx xx xxx xxxxxx xx xxx financial xxxxxxx, within xxxx xxxxx xxxx the xxxx xx receiving xxx xxxxxxx xxxxxxx. X xxxx xxxxxxxxxxx xxxx, xxxxx xxx xxxxx of the xxxx-xxxx period, I xxx xxxx xx xxxxxxxxxxx asking the Xxxxxxxx xx Xxxxxxx xx waive xxx xxxxx'x xxxxx xxx xxx xxxxxx of xxx xxxxxxxx support, xxxxxx xxxx x xxxxxx xx xxxx xxxxxxxx xx my xxxxxx xxxxxxxx, xxx xxxxx xxxxxx of xxxx suffered xxx xxx xxxxxx of xxxxxxxxxxxx xxxxxxxx.

X xxxx xxxxxxxxxxx xxxx consciously xxxxxx false xx xxxxxxxxxx information xx xxxxxxxxxxx information xxx xxx purposes of xxxxxxxxxxxxx xxxxxxx benefits xxx xxxxxxxxx xx xxxxxxx xxxxxxxx to §21, xxxxxxx 1, xxxxxx x) xx Xxx xx. 200/1990 Xxxx., on xxxxxxxx xx amended.

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Signature xx xxx xxxxxxxxx or xxx/xxx xxxxxxxxxxxxxx

- Xxxx xxxxxxx of the xxxxxxxxxxx xxx xxx xxxxxxxxx xx xxxxxxxxx xxxxxxx xxxxxxxx to Xxx Xx. 209/1997, xxx Xxxxxxxx of Xxxxxxx shall xxxxxxx xxxxxxx xxx xxxxxx xx a xxxxxx xxxxxx. Subsequently, the Xxxxxxxx xxxxx xxxxxxxx xx xxxxxxxxxxxxx with xxx xxxxxx xx x similar xxxxxxxxx xx per the xxxxxxxx xxxxxxx xx xxx case. Within xxxxx months from xxx xxxx of xxx xxxxxxx of xxx application xxx xxxxxxxxxx xx xxx xxxxxxxxx xxxxxxxxx, xxx Xxxxxxxx xxxxx xxxxxx xxxxxxx the xxxxxxx xx xxxxxx xxx xxxxxxxxx xx xxx xxxxxxx xxx such xxxxxxx xxx been xxxxxxxx.

- Xxx xxxxxxxxx xxxxx be considered x xxxxxx xx xxx Act No. 209/1997 Xxxx. only xx xx/xxx xxx xxxxxxxx xxxxxx harm xx x xxxxxx xx the commitment xx a crime. X xxxxxxxxx xxx xxx xxx xxxx xxxxxxxxx for xxx xxxxxx'x receipt xx xxxxxxxx xxxxxxx xxxxx xx the xxxxxx xx xxx point-based xxxxxxxxxx xx the xxx xxxxxxxx (not xxx xxxxxxxxx xx xxxxxx position), which xxxx xx xx xxxxx 100 xxxxxx. Xxxxxxxxx xx a xxxxxx xxx has xxxx xx xxxxxxxxxxx xx x xxxxx xxxxx be xxxxxxxxxx xx xx a xxxxxx if the xxxxxxxx xx a xxxxxx, xxxxxx xx xxxxx xx the xxxxxxxx and xxx xxxxxxxx xxxxxx x xxxxxxxxx xxxx the xxxxxxxx xx xxx xxxx of xxx/xxx xxxxx xx if xxx deceased xxxxxxxxx xx xxx required xx support the xxxxxxxx.

- Xxx Xx. 209/1997 Xxxx. xx xxx xxxxxxxxx xx xxxxxxxxx support xx xxxxxxx xx xxxxxxxx xxxx xxxxxxxxxx x xxxxxxxxxx xxxx of 1 xxxx from xxx xxxx on xxxxx the victim xxxxxxx of the xxxx xxxxxx xx xxx xxxxx. If xxxx xxxx xxxx xxx xxxxxxxx xxxx xxx xxxx xx xxx xxxxxxxxxx of xxx crime, xxx xxxxxx shall xxxxxxx xxxxxxxx of xxx xxxx on which xx/xxx xxxxxxx xx xxx xxxxxxxxxxxx. Xxx Xxxxxxxx xx Xxxxxxx xxxxxx xxxx an xxxxxxxxxxx xxx the xxxxxxxxx xx xxxxxxxxx xxxxxxx xxxxxxxx anytime xxxxx the xxxxx xx the xxxxxxxxxxxxxx xxxxxx.

- Xxxxxxxxx xxxxxxx xx xxxxxxx xxx xx a victim xxx xxx xxxxxxxx xxxxxx xxxx xx x result of xxx xxxxxxxxxx of x xxxxx xxx xx xx xxx xxxx xx x xxxx xxx xxxxxxxxx xx CZK 25,000 xx an xxxxxx xxxxx xx lost xxxxxx or xxx xxxxx xx xxxxxxx xxxxxxxxx xx proved xx xxx xxxxxx, xxxxxxx by xxx xxxxxx xxxxxxxxxx paid xx the xxxxxx xx xxxxxxxxxxxx for xxx xxxx incurred. Xxx xxxxx xxxxxx xx such support xxxx xxx exceed XXX 150,000. Xx, xxxxx xxx provision xx xxxxxxx, xxx xxxxxx proves xxxx xxx harm suffered xxxxxxx xxx xxxxxx xxxxxxxx, xxx xxxxxx xxx xxxxxxx xxxxxxxxxx xxxxxxx xx xx xxx xxxxxx xx XXX 150,000 if xx/xxx xxxxxxx xxx xx xxxxxx xxx xxxxxxxxxxxxxx xxxxxx xx xxxx (x.x., 1 xxxx xxxx xxx xxxx on which xxx xxxxxx learned xx the xxxx xxxxxx xx the xxxxx); in xxxx xxxx, xxx amounts xxxxxxx xxxx xxxx xx xxxxx xxxx xxxxxxx.

- Xx individual xxx is a xxxxxxxx xx a xxxxxx who has xxxx as a xxxxxx of xxx xxxxxxxxxx xx x xxxxx (x xxxxxx, xxxxxx xx child xx xxx deceased xxxxxx xx x xxxxxx xxxxxxxxx xxxx xxx xxxxxxxx xx xxx xxxx xx xxx/xxx death or xxxxxxxxx by or xxxxxxxx xx xx xxxxxxxxx by xxx xxxxxxxx) shall xx xxxxxxxx xxxx x xxxx sum xxxxxxxxx xx XXX 150,000. Xxx total xxxxxx xxxxxxxx xx xxxxxxxxx xxxxxxx xxxxx xxx xxxxxx XXX 450,000; xxxxxx the number xx xxxxxxx xxxxxx xxxxx, xxx xxxxxx xxxxxxxx xxx xxxxxx xxxxx be xxxxxxx xxxxxxxxxxx.

- Act Xx. 209/1997 Xxxx. xxxx xxx replace xxx xxxxxxxxx xx xxx xxxxxxxxx xxxxxxxxx of xxxxxxxxx of motor xxxxxxxx related xx xxxxxxxxxx xxxxxxxxx xxxxxxxxx. Xx matters related xx xxxxxxx accidents, xxxxxxxxxxxx xxx xxxxxxxxx xxxxxxxx xxxxxx xxxx xx xxxxxxxx to xxx xxxxxxxx providing xxxx liability xxxxxxxxx. Xxxx xx isolated xxxxx, in view xx exceptional xxxxxxxxxxxxx, xxx an xxxxxxxxxxx xxx xxx xxxxxxxxx xx xxxxxxxxx xxxxxxx xx xxxxx with xxx Ministry xx Xxxxxxx.

- Xxxxxx bear xx mind that xxx xxxxxxxxx xxxxxxxxx xxx xxxxxxxxxxxxx xxxxxxxx xxx xxx respective xxxxx xxxx be xxxxxxxx to xxx xxxxxxxxxxx. Xx xxx xxxxxxxxx xxxxx xx xx xx, xxx Xxxxxxxx xx Justice xxxxxx xxxxxxxx process xxx application. Should xxx applicant xxxx xx xxxxxxx xxx xxxx xxxxxxxxx xxx xxxxxxxxxxxxx xxxx xxxxxx x xxxxxxxxxxxxx xxxxxxxx, xxxx fact xxx xxxxxxx x xxxxxxxx xx xxxxxxxx xxx xxxxxxx xx xxx Xxx Xx. 209/1997 Xxxx. Xxxx shall xxx, xxxxxxx, xxxxxxxxx xxx filing xx xxxxxxx application.

- Please xxxx xx xxxx xxxx xxx xxxxxxxxx xxxxx be xxxxxxx xx xxxxxx xxx xxxxxxxxx xxxxxx xxxxxxxx xx xxxxxxxxxxxx for xxxx (from xxx xxxxxxxx, xxxxxxxx etc.) xx the account xx the Ministry xx Xxxxxxx xx xx xxx xxxxxx xx xxx xxxxxxx xxxxxxxx. This xxxxxxxxxx xxxx not apply xx he/she xxx xxx xxxxxxxx xxx xxxxxxxxxxxx. If xx xxxxxxxxx xx xxx xxxxxx xx xx xxxxxxxxxxx, xxx Ministry xx Xxxxxxx may xxxxx xxx xxxxx'x xxxxx to claim xxx return xx xxx xxxxxxxxx xxxxxxx xxxxxxxx after xxx xxxxx xx xxx xxxx-xxxx xxxx, xxxxxxxx xxxx a xxxxxx xx justified xx xxx xxxxxx'x xxxxxx xxxxxxxx, xxx xxxxx xxxxxx of the xxxx xxxxxxxx and xxx xxxxxx xx xxxxxxxxxxxx xxxx to xxx xxxxxx.

Xxxxxx xxx/xxxx/xxxxxx

Xxxxxxxxxxxxxxx xx, že x xxxxxxxx, x xxxxxx xx xxxxxxxxxx, xxx xxxxxx Vás xxxxxxxxx xxxxxxxxxxxx otázkami. V xxxxxx xxxxxxxx posúdenia Xxxxx xxxxxxxx x xxxxxxxxxxx peňažnej xxxxxx xxxxxxx xxxxxxxx xxxxxxxx xxxľx xxxxxx č. 209/1997 Zb., xx xxxx xxxxxxxxx xxxxx dotazníku xxxxxxxxxx. Xxxxxxxx Xxx za xxxxxxxxxx, xxxxx xx xxxxx xxxxxx.

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X. Xxxxxx, xxxxxxx xxxxxxľxx xxxxxx xxxxx x xxxxxxxľxxx - xxxxx trestného xxxx, xxxxxx spôsobili xxxx na xxxxxx, xxxxx xxxxx xxxxxxxxxx xx osobe, xxxxx x xôxxxxxx trestného xxxx xxxxxxx:

1. Xxxxxxxxxx:

2. Xxxx:

3. Dátum xxxxxxxxx:

4. Xxxxxx xxxxxxxx xxxxxx:

5. Xxxxxxxxxxxxxx xxxxxx (x xxxxxxx, xx sa xxxx xx xxxxxx xxxxxxxx xxxxxxxx):

6. Telefón:

7. X-Xxxx:

8. Občianstvo:

II. Xx xxxxxxxľx xxxxxxxxx xxx xxxxx (xxxxxxxx) na xxxxxxx zákonného zastúpenia (xxxx. xxxxxxxx dieťa xxxxxx rodičom) xxxxx xx základe dohody x xxxxx moci, xxxxxxx xxxxx o xxxxxxxxxx:

1. Xxxxxxxxxx:

2. Xxxx:

3. Xxxxxxxxxxxxxx adresa:

Ak žiadate xx xxx xxxxx, xxxx sa xxxxxxx xxxxxxxxxx, xxxxx xxxxxxxxxx xxxxxxx. Xxxxx x xxxxxxxx priložte kópiu xxxxx xxxx (pri xxxxxxxx xxxxxxxxx) alebo xxxxx xxxxxxx xxxxx (x xxxxxxx zákonného xxxxxxxxxx) alebo inú xxxxxxx listinu.

III. Xx xxxxxxxľ xxxxx xxxxx xxxxxxxxx xx xxxxx, xxxxx x dôsledku xxxxxxxxx činu zomrela, xxxxxxx, xxxxxx, aj xxxxx o umretej xxxxx:

1. Priezvisko:

2. Xxxx:

3. Xxxxx narodenia:

4. Dátum xxxxxx:

5. Xxxxxxxx bydlisko:

7. Xxxxxxxxxx:

8. X xxxx xxxxxx xxxx zomretá xxxxx v xôxxxxxx xxxxxxxxx xxxx k xxxxx xxxxxxxľx (xxxx, xxxxx, xxxxx xxxxxx x xxxxxxxxx domácnosti):

Ak xx xxxxxxxľ osobou xxxxxxxxxx xx osobe, xxxxx v dôsledku xxxxxxxxx xxxx zomrela, x xxxxxxxx xx xxxx xxxxxxxx xxxxx xxxxxxxx xxxxx x xxxxxxx, ktoré dokladajú xxxxxxxxxx, xx umretá xxxxx xxxxxxxxxx xxxxxxxxx xxxxx alebo xxxx xxxxxxxxx xx xxxxxxxxx (xx xxxxxx xxxxx - xxxxx xôxxx x rodný list xxxxx xxxxxxxxxxx súdu x xxxxxxxxxxx xxxxxxxxxx, xxx xxxxxxxx xxxxx xxxxxxxx bude sobášny xxxx x xxx.)

XX. Xxxxxx, xx xxxxxxx xxxxxxxx peňažnú xxxxx xxxxxxxxxxxxxxx xxxxx xxxxx xxxxxxxx xx xxxxxxx xxxx; x xxxxx xxxxxxx xxxxxxx oznámte xxxxx Xxxxx účtu.

V. Xxxxxx xxxxx, xxxx xx xxxx xxxxxxxxx x xxxxx xxôxxxxxxx xxxxxxxx xxxxx.

Xxxxxx xxxxx xxxxxxxxx trestného xxxx x xx xx xxxx x xxxxx xxx spôsobenej dozvedela xx xxxxôx, xxxxxx xxxx x xxx (xxxxxxxxx z xxxxxxxxx xxxxxx - dátum xxx xxxxxxxxxx).

XX. Označte xxxxx činný x xxxxxxxx xxxxxx (xxxxxxxxx xxxxx, xxxxxx xxxxxxxxxxxxxx, xxx), xxxxx naposledy xxxxx xxxxxxx x xxxxxxxx čine. Xxxxxx xx spisovú xxxxxx, xxx xxxxxx xxxxxxxx xxxxxxxxxxxx.

Xx xxxx k xxxxxxxxxx xxxxxxxx rozhodnutie xxxxxx xxxxxxx x xxxxxxxx xxxxxx, xxxxx xxxx xxxxxxxxx x xxx, x akom xxxxxx sa xxx xxxxxxxx (xxxx. xxxxxxxxx x xxxxxxxx xxxxxxxxx xxxxxxxx, xxxx xxxxxxxx, xxxxxxxx - i xxxxxxxxxxxxx), xxxxxxxx xx x xxxxxxxx.

XXX. Uveďte, xxxx spôsobom xxx xxxxxxxxx xxxxx xx xxxxxxx xxxxx od xxxxxxxľx alebo xxxx xxxxx, xxxxx xxxxxxxxx xx xxxxx.

Xxxľx xxxxxxxxxxx §8 zákona x. 209/1997 (Xx)., xxxxxxxx xxxxx xx xôxx xxxxxx alebo sa xxxxxxxx x prihliadnutím xx to, xx xxxx využila xxxxxx xxxxxxx xxxxxxxxxxx xx xxxxxxxxxx xxxxxx na xxxxxxx xxxxx xx xxxxxxxľx xxxxx inej xxxxx, xxxxx xxxxxxxxx xx škodu. Tento xxx xxxxxxxxxxx, xx xxxxxxxľx trestného činu xxxxxxxxx.

Xxx XXXX. Vyplňte, xx xxxxxxxľ je xxxxxxxxxx xx osobe, xxxxx v xôxxxxxx xxxxxxxxx xxxx zomrela.

VIII. Xxxxxx, xx xxx xxxxxxx xxxxxx, ktorá xxľxx podmienky xxxxxxx x §2 odst. 2 xxxxxx č. 209/1997 Zb., prípadne xxľxx xxôx xxľxx xxxxx podmienky, ak xx Vám xxxxx xxxxxxxxxxx známe.

1. Boli xxx xxxxxxx, xxxxxxxx xxxxx xxxxxxxx xxxxx, xxxxx xxxxxxx v xôxxxxxx trestného xxxx?

2. Xxxx xxx x xxxxxx xxxxxxxxx xxxx xxxx vykonaním xxxxxxxxx xxxx x xxxxxxxxx xxxxxxxxxx?

3. Poskytovala Xxx xxxx trestného xxxx xxxxxx, xx xxxx x xxxx xxxxxxx?

4. Xxľxxxx xxxxx osoby xxxxxxxxxxx xxxxxxxxx 1 xx 3? Uveďte xxx xxxxx, ak Xxx xx známy.

Podľa xxxxxxxxxxx §2 xxxx. 2 zákona č. 209/1997 Xx. xx xx obeť xxxxxxxx xxxxx pozostalá xx xxxxx, ktorá v xôxxxxxx xxxxxxxxx xxxx xxxxxxx, xx je xxxxxxx, manželom xxxxx xxxxxxxx xxxxxxxxx a xxxxxxx v xxxx xxxx xxxxx x xxx xxxx v xxxxxxxxxx xxxxx osoba, xxxxxx xxxxxx xxxxxxxxxx xxxxx xxx xxxxxxx xxxxxxxxxx xxxxxx.

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Xxxx XX. xx XXX. Xxxxxxx, xx xx xxxxxxxľ xxxx xxxxxx xxxxxxxxx xxxx x xxxx xx spôsobená xxxx xx xxxxxx.

XX. Xxxxxx xxxxx, kedy xx xxxxxxxx liečenie, respektíve xxxx xx skončila xxxxxxxx neschopnosť.

X. Xxxxxxx xxxxx xxxxxxxx xxxxxxxxxxx xx xxxxxx xxxx:

X xxxxxxxx xx xxxx xxxxxxxx xxxxxx ohodnotenie xx xxxxxx podľa xxxxxxxx č. 440/2001 Zb., ktoré xxxxxxxľ získa od xxxxxx, ktorý ho xxxxxxxxx. Xxxxx xxxxxxxx xxxxxxx xxxx xxxxxxxxx xxxxxx xxxxxxxxxx vytrpenej xxxxxxx a xxxxxx xxxxxxxxxx xxxxxxxx xxxxxxxxxxxxx xxxxxxxxxx. Xxxxxxxxxxx, xx xxx xxxxx xxxxxx č. 209/1997 Zb. xx xxxxxxxxxx xxx xxxxxx xxxxxxxxxxx xxxxxxxxx bolesti. Podľa xxxxxxxxxxx §6 xxxx. 2 xxxxxx x. 209/1997 Xx. nemožno xxxxxxxxx' xxxxxxx xxxxx, xx xxxxxx ohodnotenie xxxxxxxxx xxxxxxx xxxxxxxxxx xxxxxxxx 100 xxxxx.

XX. Xxxxxx, či xxxxxxx x xxxxxxxxxxx xxxxxxxx xxxxxx xx xxxxx xxxxxxxxx čiastky 25&xxxx;000.- Xx alebo xx xxxxxxxx xxxxx xxxxxx xxxxxxx x xxxxxxxx xx liečenie.

Podľa xxxxxxxxxxx §7 xxxx. 1 xxxx. x) xxxxxx x. 209/1997 Xx. xx žiadosť xxxxx xxxxx xxxxxxxxx xxxxxxx xxxxx xx xxxxx xxxxxxxxx xxxx 25&xxxx;000.- Xx, xxxxx xx xxxxx xxxxxxxxxxxxxx preukázaným xxxxxxxx xx liečenie x ušlému xxxxxxx. Xx xx xxxxxxxxxx xxxxxx x xxxxxxx xxxxx xx výške xxxxxxxxx čiastky, nemusíte xx vyplňovať xxxx XXX. - XIV. xxxxx dotazníka.

XII. Xxxxxxx xxxxxxx x xxxxxxxx xxxxxx:

Xxx o náklady xx xxxxx, zdravotnícke xxxôxxx, náklady xx xxxxxxxxxxxxx, xxxxxxxxx xxxxxx xxxxx xx pomoc x xxxxxxxxxx xx xxxxxxxxxx, xxxxxxx xxxxxxx xx dopravu, x xxx. xxx xxxxxxxxxx, xx xxxxx náklady xxxxxxxxx xxxxxxxxx. Tu xxxxxxx xxxxxxx xx xxxxx xxxxxxx, xxxx xx ne xxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxx mócť xxxx xxxxxľ.

XXXX. Xxxxxxx xxxxxxxxx xxxxxx žiadateľa xxxx a po xxxxxx xxxx xx xxxxxx xxôxxxxxxx trestným xxxxx.

X xxxxxxxx xxxxxxxx xxxxxxx, ktoré xxxxxxxxxx xxxxxxx xxxxxxxxxxx.

X prípade, xx žiadateľ xx x zamestnaneckom pomere, xôxxx x xxxxxxxxxx xxxxxxxxxxxxľx o priemernom xxxxxxx xxxľx §351 x xxxx. zákona x. 262/2006 Xx., xxxxxxxx práce, v xxxxx neskorších xxxxxxxxx. Xx xx žiadateľ xxxxxx xxxxxxxxxx zárobkovo xxxxxx, xxxxx listinou xxxx xxxxxxxxx xxxx xxxxxxxxxx xxxxxxxx priznania. Xx xxxxxxxľ xxxxxx xxxxxxxx xôxxxxxx, xxxxxxxx, xxxxx môže xxxxxxx xxxxxxxx sociálnu situáciu, xxxx potvrdenie o xxxxx starobného dôchodku. X xxxxxxx, xx x nejakého závažného xôxxxx xxxxxxx xxxxxxx xxxxxxxxx pomery xxxxxxxľx, x xxxxxxx xxxxxxx xx xxxxx xxxxxxxx xxxxxxxxxx o xxxx xxxxxxx xxxxxxxxxx.

XXX. Xxxxxx xxxxx nemocenských dávok (xxxxxxxxxxx dôchodku) a xxxx, xxxxxx xxx xxxxxxxľ xxxxxx, xx xxxxxxx po xxxxxx xxxx xx xxxxxx, xxôxxxxxxx xxxxxxxx xxxxx.

X xxxxxxxx xxxxxxxx xxxxxxxxxx xxxxxxxxxxxxľx xxxxx xxxxxxxxx x výške nemocenských xxxxx. V xxxxxxx, xx x xôxxxxxx xxxxx xx zdraví xxôxxxxxxx trestným xxxxx Xxx xxxxxxxx xxxxxxxxx xôxxxxxx, xxxxxx a xxxxxxx xxxx xxxxx.

Xxxx xxxxxxxxx pomery xx také, xx xxxxxxxx xxxxx, ktorého xxx xxx(x) xxxxxx, xx xxxx xxxxxxxx xxxxxxxx xxxxxxxx. Xxxxx, xxxxx mi xxxxx xxôxxxxx, dosiaľ xxxxxx xxxxxxxx.

Xxxxxx vyhlasujem, xx xxxxx xx peňažnú xxxxx xx xxxxxxx xxxxx xx xxxxxxxxxxx xxxx spôsobenej xxxxxxxx xxxxx xxx xxxxxxxxxx(x) x žiadnom inom xxxxx xxx x Xxxxxx (Slovenskej) xxxxxxxxx.

Xxxxxx xx xxxxxxx, xx xx xxxľx ust. §12 zákona x. 209/1997 Zb., x xxxxxxxxxx xxxxxxxx pomoci xxxxxxx xxxxxxxx činnosti x x zmene x x doplnení xxxxxxxxxx xxxxxxx, x xxxxx xxxxxxxxxx xxxxxxxxx, xxxxxx xxxxxxxxx xx xxxxxxx xxxxx xxx xxx, xxx mi xxxxxxxx pomoc, odviesť xx účet Ministerstva xxxxxxxxxxxxxx xxxxxxx, xxxxx xxx xxxxxx(x) xxx xxxxxxx xxxxx, x xx až xx xxxxx poskytnutej xxxxxx. Xxxxxxx x xxx xxxxxx na xxxxxxx, xx xx xxxxxxxx xxxxxxxxxx päťročnej xxxx xôxxx požiadať Xxxxxxxxxxxx xxxxxxxxxxxxxx, xxx xx x mene xxxxx xxxxxx xxxxx na xxxxxxxx xxxxxxxxxxx xxxxxx, xx moja xxxxxxxx xxxxxxxx xxxx taký xxxxxx xxôxxxxxxxx, xxxxxxx xxxxx xxxxx, xxxxx xx spôsobili x xxxxx xxxxxxx, ktorú xxx xxxxxx(x).

Xxxxxx xxxx xx vedomie, xx xxxxxxxxx xxxxxxxx xxxxxxxxxxx xxxxx neúplného údaja xx jeho xxxxxxxxx xx účelom xxxxxxxx xxxxxxxxxxxx xxxxxx, xx xôxxx xxxxxxxx xxxxxxxxxx xxxľx §21 xxxx. 1 xxxx. x) xxxxxx č. 200/1990 Xx., x priestupkoch, x xxxxx xxxxxxxxxx xxxxxxxxx.

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xxxxxx žiadateľa alebo xxxxxxxx

- Ministerstvo spravodlivosti Xxxxx xxxxxxxxx xx xxxxxxx xxxxxxxx x xxxxxxxxxxx xxxxxxxx xxxxxx xxxľx xxxxxx č. 209/1997 Zb. xxxxxxx jej príjem x xxxxx xxxxxxxx xxxxx. Potom xxxx xxxxxxxxxx xx polícii xx xx xxxx xxxxxxxx xxxxxx xxxľx xxxxxxxxxxx okolností prípadu. Xx xxxxx xxxxxxxx xx xxxxxx žiadosti x xxxxxxxxxx xxxxxxxxxx xxxxxxxx buď xxxxx xxxxxxxx alebo xxxxxxxľxxx xxxxxx xôxxxx, xxxxx xxxxx xxxxxxx poskynúť.

- X xxxxxx xxxxxx č. 209/1997 Zb. xxxx xxxxxxxľ xxxxxxxxxx xx obeť xxx x xxxxxxx, xx xx v xôxxxxxx xxxxxxxxx činu xxxx spôsobené poškodenie xxxxxxx. Xxxxxxxxxxx, nie xxxx postačujúcou podmienkou xx xxxxxxxxx peňažnej xxxxxx xxxxx xxxxx xx xxxxx xxxxxxxx xxxxxxxxxxx xxxxxxx (xxx xxxx xxxxxxxx xxxxxxxxxxxxx xxxxxxxxxx) dosahujúceho xxxxx 100 bodov. Xx xxxx xx xxxxxxxx xx osoba xxxxxxxxx xx xxxxx, xxxxx x xôxxxxxx xxxxxxxxx xxxx zomrela, ak xxxx xxxxxxx, xxxxxxxx xxxxx dieťaťom zomretého x zároveň v xxxx xxxx smrti x xxx xxxx x xxxxxxxxxx, xxxxx xxxxx, xxxxxx xxxxxxx xxxxxxxxxx xxxxx xxx xxxxxxx xxxxxxxxxx výživu.

- Xxxxx č. 209/1997 Zb. o xxxxxxxxxx xxxxxxxxx xxxxxx xxxxxxx xxxxxxxx činnosti xxxxxxxxx xxxxxxxxxxx (xxxxxxxx) xxxx 1 roka xxx dňa, xxx xx xxxx xxxxxxxxx x xxxxx spôsobenej xxxxxxxx xxxxx. Xx xxxxx xxxx xx xxx je deň xxxxxxxxx xxxxxxxxx xxxx, xxxx dokazuje okamžik, xxxx xx to xxxxx. Xxxxxxxxxxxx spravodlivosti xxxôxx xxxxxxxx žiadostiam x xxxxxxxxxxx peňažnej xxxxxx, xxxxx xx xxxxxxxx po xxxxxxxx xxxxxxxxxx lehoty.

- Pomoc xx na žiadosť xxxxx, xxxxxx v xôxxxxxx trestného xxxx xxxxxxx škoda na xxxxxx, poskytne v xxxxxxxxx xxxx 25&xxxx;000.- Xx alebo vo xxxxx, xxxxx xxxxxxxxxxx xxxxxxxxxx stratu xx xxxxxxx, preukázané xxxxxxx xxxxxxx s liečením, xxxxxxx x xxxxx xxxxxxxx xxxxxxx, ktoré xxxx x titulu xxxxxxx xxxxx už xxxxxxx; xxxxx xx xxxxxx xxxxx xxxxxx xxxxxxxxxx xxxx 150&xxxx;000.- Xx. Xx xxxx - xx xxx, xxx xxx poskytli xxxxx - xxxxxxxx, xx jej xxxxxxxxx xxxxx xx xxxxxx xxx tá, ktorá xxxx podkladom na xxxxxxxxxxx pomoci, xx xxx žiadosť v xxxxxx stanovenej týmto xxxxxxx xxx xxxxx xxxxxxxxx pomoc xxäx, x xx xx xx maximálnej xxxxx 150&xxxx;000.- Xx; pričom xx prihliadne xx xxxxxxx, ktoré xx xxxx xxxxxxxxx.

- Xxxxxxxx xxxxx, ktorá xx xxxxxxxxxx xx xxxxx, xxxxx x xôxxxxxx xxxxxxxxx činu xxxxxxx (xx bola xxxxxxx, xxxxxxxx alebo xxxxxxxx xxxxxxxxx x xxxxxxx x xxxx xxxx xxxxx x ním xxxx x xxxxxxxxxx, xxxxx xxx zomretý xxxxxxxxxx, xx xxx xxxxxxx poskytovať xxxxxx), xx poskytne xxxxxxx xxxxx x xxxxxxxxx xxxx 150&xxxx;000.- Xx; xxxxx xx xxxxxx xxxxx xxxxxx presiahnuť xxxx 450 000.- Xx, x xx xx xxxxx xxxxx xxxx xxx tri xxxxx, xxxxxxxxxxx xxxxxxx xx xxx každej xxxxx xxxxxxxxx xxxxx.

- Xxxxx č. 209/1997 Zb. xxxxxxxxxxxx xxxxxxxx xxxxxxxxxxx zodpovednosti vykonávateľa xxxxxxxxxx xxxxxxxx, xx xxxxx xxxxäxxxx povinné xxxxxxx poistenie xxxxxxxxxxxxx. Xxxxx je potrebné x záležitostiach dopravných xxxôx xxxxxx xxxxxxx, xxxxx xxxxxxxx poistenie xxxxxxxxxxxxx, x xxxxxxxxxxx xxxxxxxxx xxxxxxx. Xxx x xxxxxx ojedinelých xxxxxxxxx x xxxxxxxxxxxxx xx xxxxxxxxx xxxxxxxxx xxxxxxxxx xx xxxxx xxxxxx xxxxxxxxxxxx xxxxxxxxxxxxxx x poskytnutie peňažnej xxxxxx.

- Pripomíname, xx xx xxxxxxxxxx priložiť xxxxxx xxxxxxxx doklady x xxxxxxxxxx, xx xxxxx odkazujeme xxx xxxxxxxxxxxx xxxxxxxxx. Ak xxx xxxxxxxľ xxxxxxx, xxxxxxxxxxxx spravodlivosti nemôže xxxxxxx xxxxxxx. Xx xxxxxx potvrdenia a xxxxxxx xxx xxxxxxxxx xxxxxx, táto xxxxxxxxxx xôxx xxx xôxxxxx xxxxxxxxxxxxx xxxxxxxx pomoci xxxľx xxxxxx č. 209/1997 Zb. Xx xxxx xxxxxxxxxx xxxxxxx xxxxx xxxx xxxxxxx.

- Xxxxxxxxxxxx, že xx xxxx xxxxxxxľxxx xxxxxxxxxx xxxxxxx xxxxx, xxxxxxxľ je do xxxxxxx xxxxx odo xxx xxxxxxxxxxx xxxxxx xxxxxxx xx účet xxxxxxxxxxxx xxxxxxxxxxxxxx xxxx, xxxxx dostal ako xxxxxxx xxxxx (od xxxxxxxľx, xxxxxxxxx x xxx.) xx xx xxxxx poskytnutej xxxxxx. Xxxx xxxxxxxxx nemá, xx xx škodu xxxxxxxxxx. Xx xxxxxxx xxxxxxxx xxxxx xx xxxxxxxxxxxx xxxxxxxxxxxxxx xôxx x xxxx xxxxx xx uplynutí xxxxxxxxxx xäxxxxxxx xxxx vzdať xxxxx xx vrátenie xxxxxxxxxxx xxxxxxxx xxxxxx. Xx xxxxxx postup xxôxxxxxxx xxxxxxxx xxxxxxxx xxxxx, xxxxxxx výška xxxxx, ktorú xxx xxôxxxxxx, x výška xxxxxxx, xxxxx xxxx xxxxxxx.