Plné znění - 241/2006 Sb.

Questionnaire xxx the Assessment xx Applications xxx xxx Xxxxxxxxx xx Xxxxxxxxx Xxxxxxx xx Xxxxxxx xx Criminal Xxxx pursuant xx Xxx Xx. 209/1997 Xxxx., on xxx xxxxxxxxx xx xxxxxxxxx xxxxxxx to the xxxxxxx xx criminal xxxx xxx on xxxxxxxx xxxxxxx xxxxx xxxx, xx xxxxxxx

Xxxx Xxx/Xxxxx,

Xx xxxxxxxxx xxx xxxxxxxxx you xxxx xxxxxxxx xxxxxxxxx xx xxxx xxxxxxx xxxxxxxxx. Xxxxxxx, xxxxxxx xx xxxx xxxxxxxxxxxxx is xxxxxxxx xxx xxx xxxxx xxxxxxxxxx xx xxxx xxxxxxxxxxx xxx xxx xxxxxxxxx of xxxxxxxxx xxxxxxx pursuant xx Xxx no. 209/1997. Thank you xxx xxxx xxxxxxxxxxx; xx xx xxxxxx xxxxxxxxxxx.

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X. Xxxxxx legibly xxxx xx xxx xxxxxxxx data of xxx xxxxxxxxx - x.x. xxx xxxxxx xx xxx xxxxxxxx xxx who xxx xxxxxxxx xxxxxx xxxx, xx the xxxxxxxx xx x xxxxxx xxx has died xx xxxxxxxxxxx xx xxx criminal xxx:

1. Xxxxxxx:

2. Xxxxx xxxx:

3. Xxxx of birth:

4. Xxxxxxxxx address:

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

6. Phone Number:

7. X-xxxx xxxxxxx:

8. Nationality:

II. Xx xxx xxxxxxxxx xx xxxxxxxxxxx by xxxxxxx person ("xxxxxxxxxxxxxx") xx xxx xxxxx xx xxxxxxxxx xxxxxxxxxxxxxx (xxx xxxxxxxx, a xxxxx xxxxx xxxxxxxxxxx xx his/her xxxxxx) xx xx xxx xxxxx of x xxxxx xx xxxxxxxx, xxxxxx xxxx xx xxx data of xxxx representative:

1. Xxxxxxx:

2. Xxxxx xxxx:

3. Permanent xx xxxxxxxxxx address:

If xxx xxxxxxxxxxxxxx is xxxxxx xxx application xx xxxxxx xx xxx xxxxxxxxx, xxxxxx xxxx xxxxxx x xxxxxxxx authorizing him/her xx xxxxxxxxx the xxxxxxxxx - x xxxx of a xxxxx of xxxxxxxx (xxx contractual representation) xx x xxxx xx xxx xxxxx xxxxxxxxxxx (xxx statutory xxxxxxxxxxxxxx) xx xxx xxxxx xxxxxxxxxx xxxxxxxx.

XXX. Xx the xxxxxxxxx xx a xxxxxxxx xx x person xxx xxx died xx xxxxxxxxxxx xx xxx respective xxxxxxxx xxx, xxxxxx xxxx xx xxx xxxxxxxx xxxx xx xxx xxxxxxxx:

1. Xxxxxxx:

2. Xxxxx xxxx:

3. Date xx xxxxx:

4. Xxxx xx xxxxx:

5. Last xxxxxxxxx xxxxxxx:

6. Xxxxxxxxxxx:

7. Relationship xx xxx deceased xx xxx applicant (x.x. xxxxxx, daughter, xx xxxxxxxxxx xxxxxx xx common xxxxxxxxx)

Xx xxx xxxxxxxxx is x xxxxxxxx xx x person who xxxx xx xxxxxxxxxxx xx xxx criminal xxx, xxxxxx xxxxxx x xxxx xx xxx xxxxx xxxxxxxxxxx xxx any documents xxxxxxx xxxx the xxxxxxxx xxxxxxxxx xx xxx xx xxxxxxxxxx xx xxxxxxx xxx xxxxxxxx (xx the xxxx of x xxxxxx-xxxxx xxxxxxxxxxxx, such xxxxxxxxx xxxxxxx xxxxx xxxxxxxxxxxx xx x xxxxx xxxxxxxx xx xxx obligation to xxxxxxx the dependent; xx xxx xxxx xx married xxxxxxx, xxxxxx attach x xxxxxxxx xxxxxxxxxxx).

Xxxxxx specify xxx xxxx xx xxxxx xxx xxxxx was xxxxxxxxx and, xx xxx victim xxxxxxx xxxxx xxx consequences xx xxx crime xx x later xxxx, xxxxxx also xxxxxxx xxx xxxx xxx the manner xx xxxxx xxx xxxxxx learned xx xxxx consequences (x.x., xxx date xx xxx xxxxxxx xxxxxx).

XX. Xxxxxx xxxxxxx xxx xxxxxxxx justice authority (x.x. xxxxxx, xxxxxx xxxxxxxxxx'x office, court) xxxxx xxxx xxxxxxxx xxxxxxxxx xxxxxxxx xxxxxxxxxxx. Xxxxx xxx xxxxxxxxx xxxxxx of xxx xxxx xxxxxxx to xxx xxxxxxxxxx proceedings.

If xxxxxxxxx, please xxxxxx xxx xxxxxx xxxxxxxx xx xxx xxxxxxxxxxxxxx xxxxxxxx xxxxxxx xxxxxxxxx xxxxx xxxxx xxxxxxxx xxx xxxxx xx xxx xxxxxxxxxx xxxxxxxxxxx (x.x. resolution xx xxx xxxxxxxxxxxxxxx of xxxxxxxx xxxxxxxxxxx, copy xx xxx xxxxxxxxxx, xxxxxxxxx - final xx otherwise).

Xxxxxxxxx xx xxx provisions xx §8 xx Xxx no. 209/1997, xxx xxxxxx xx xxxxxxxxx xxxxxxx may xx xxxxxxx or xxxxxxxx depending xx xxxxxxx xxx xxxxxx xxx xxxx xxx xx all xxxxx xxxxxxxx xx xxxxxxx x claim for xxxxxxxxxxxx against the xxxxxxxx or any xxxxx xxxxxx xxxxxxxxxxx xxx xxx xxxx xxxxxxxx. Xx xxx xxxx xx xxxx xxxx if xxx xxxxxxxx xxx xxx xxxx identified.

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Fill in xxxx XxXx if xxx xxxxxxxxx xx x xxxxxxxx xx xx xxxxxxxxxx who xxx xxxx xx xxxxxxxxxxx xx the xxxxxxxxx crime.

1. Xxx xxx a xxxxx, xxxxxx xx xxxxx xx xxx xxxxxx xxx xxxx xx consequence of xxx xxxxxxxx xxxxxxx?

2. Xxx xxx xxxx xx x xxxxxx xxxxxxxxx xxxx xxx xxxxxxxx person prior xx xxx xxxxxxxxxx xx xxx xxxxx?

3. Xxxx you a xxxxxxxxx of the xxxxxx xx was xxx xxxxxxxx xxxxxxx xx xxxxxxx you?

4. Xx xxx other xxxxxxx xxxx xxx xxxxxxxxxx xxxxxxxxx in xxxxxxx 1 xx 3? Xxxxxx give xxxxx number, xx xxxxx to xxx.

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Xxxxxxxxx xx xxx provisions xx §2, section 2 xx Xxx xx. 209/1997, x xxxxxx xxx xx x survivor xx x xxxxxx xxx xxxx xx consequence xx x criminal xxx is xxxxxxxxxx xx be x xxxxxx xx xx xx she xx x xxxxxx, xxxxxx xx xxxxx xx xxx deceased xxx xxxxx xxxx him xx xxx in xxx same xxxxxxxxx xx xx the xxxxxx was x xxxxxxxxx xx the xxxxxxxx or xxx xxxxxxxx xxx required xx xxxxxxx xxx xxxxxx.

Xx the xxxxxxxxx xx xxx xxxxxx xx a crime xxx has xxxxxxxx xxxxxx xxxx, please xxxx xx items XX - XXX.

Xxxxxx xxxxxx x xxxxx-xxxxx assessment xx pain and xxxxxxxxx xxxxxxxx xx Xxxxxx No. 440/2001 Xxxx. Xxx xxxxxxxxxx xxxxxxxx should xx xxxxxxxx from xxx xxxxxxxxx xxxxxxxxxxx xxx xxx xxxxxx'x treatment. Xxxx xxxxxxx report xxxx contain a xxxxx-xxxxx xxxxxxxxxx xx xxx xxx xxxxxxxx xxx a point-based xxxxxxxxxx of xxx xxxxxxxx xx the xxxxxx'x xxxxxx xxxxxxxx. Xxxxxx bear xx xxxx xxxx xxxx xxx xxxxx-xxxxx assessment xx xxx xxx xxxxxxxx xx relevant xxx xxx xxxxxxxx xx Act no. 209/1997. According xx xxx xxxxxxxxxx of §6, xxxxxxx 2 xx Xxx no. 209/1997, no xxxxxxxxx xxxxxxx xxxx xx xxxxxxxx xxxxxx xxx xxxxx xxxxxxxxxx of xxx pain xxxxxxxx xx xx xxxxx 100 points.

Xxx xxxxxx may xxxxxx xxxx xxx xxxxxxxxx xxxxxxx xx the xxxxxx xx XXX 25,000 or xx xxxxxx xxxxx xx xxx xxxxxx xxxxx xx medical treatment xxx lost income (§7, section 1, xxxxxx x xx Xxx No. 209/1997 Xxxx.). xx you xxxxxx xx apply xxx x lump xxx xxxxxxx, xxxxx xx xx xxxx xx fill in xxxxx XXX - XxX.

Xxxx xxxxxxxx xxx xxxxxxxx xxx xxxxxxxxxx, sanitary equipment, xxxxxxxxxxxxxx xxxxx, xxxxxx xx xxxxxxxxx xx xxxx out xx xxx xxxx xx xxxx xxxxxxx xxxxxxxxx, xxxxxxxxx transportation xxxxx xxx., xxxxxxxx xxxx xxxxx have not xxxx paid xx xx xxxxxxxxx xxxxxxx. xx xxxx xxxxxxxx xxx xxx proved xx xxxxxxxxxxx evidence, xxx Xxxxxxxx of Xxxxxxx xxx not xxxx xxxx xxxx xxxxxxxxxxxxx.

Xxxxxx attach xxx documents xxxxxxxxxx xxxx facts to xxx application.

If xxx xxxxxxxxx xx an xxxxxxxx, xxxxx xxxxxxxxx xxxxx xxxxxxx x xxxxxxxxx xxxx xxx/xxx xxxxxxxx xxxxxxxxxx xxx xxxxxxx xxxxxx xxxxxxxxx xx §351 xx. xxx. of Xxx xx. 262/2006, the Xxxxx Labour Code, xx xxxxxxx. xx xxx xxxxxxxxx is xxxx-xxxxxxxx, such document xxxxx xx x xxxx xx xxx/xxx xxxx xxxxxx xxx xxxxxx. xx the xxxxxxxxx xx a xxxxxxx xxxxxx who xx able xx xxxxx xxx/xxx xxxxxxxx xxxxxx standing, xxxxxx xxxxxx x document xxxxxxxxxx xxx xxxxxx xx the retirement xxxxxxx. lf for xxx xxxxxx xxx xxxxxxxxx'x xxxxxx xxxxxxxxx xxxxxx be proven, xx xxxxxxxxxxx xxxxx xx xxxxxxxxx may xx xxxxxxxx.

My xxxxxx xxxxxxxx has xxxx impaired xx x result xx xxx xxxxxxxx xxx xx xxxxx I xxx a xxxxxx. X have xxx xxx xxxx compensated xxx xxx xxxx 1 xxxx xxxxxxxx xx a xxxxxx xx xxx xxxxxxxx xxx.

X hereby xxxxxx xxxx X have xxx xxxxxx any xxxxx xxx financial xxxxxxx xx any xxxxxxx xxxxx xxx xxxxxxxxxxxx xxx xxx xxxx xxxxxxxx xx x result xx xxx xxxxxxxx xxx xx any xxxxxxx xxxxx than xxx Xxxxx Xxxxxxxx.

X xxxxxxxxxxx xxxx xxxxxxxxx xx §12 of Act Xx. 209/1997 Xxxx., xx xxx xxxxxxxxx xx xxxxxxxxx xxxxxxx xxx the xxxxxxx xx xxxxxxxx xxxx xxx xx xxxxxxxx xxxxxxx xxxxx xxxx, xx amended, X xx obliged xx xxxxxxxxx the Xxxxxxxx xx Xxxxxxx any xxxxxx xxxxxxxx xx xxxxxxxxxxxx xxx xxx xxxx xxxxxxxx, xx xx xxx xxxxxx xx xxx xxxxxxxxx xxxxxxx, within xxxx xxxxx xxxx xxx xxxx xx receiving xxx funding support. X xxxx acknowledge xxxx, after the xxxxx of the xxxx-xxxx xxxxxx, X xxx xxxx xx xxxxxxxxxxx asking xxx Xxxxxxxx xx Justice xx xxxxx xxx xxxxx'x xxxxx xxx xxx return xx xxx provided xxxxxxx, xxxxxx such x xxxxxx be xxxx xxxxxxxx by xx xxxxxx xxxxxxxx, the xxxxx extent of xxxx suffered and xxx xxxxxx xx xxxxxxxxxxxx xxxxxxxx.

X also xxxxxxxxxxx xxxx xxxxxxxxxxx xxxxxx xxxxx xx xxxxxxxxxx xxxxxxxxxxx xx xxxxxxxxxxx xxxxxxxxxxx xxx xxx purposes of xxxxxxxxxxxxx xxxxxxx benefits xxx represent an xxxxxxx xxxxxxxx xx §21, xxxxxxx 1, xxxxxx x) xx Xxx xx. 200/1990 Xxxx., on xxxxxxxx xx amended.

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Signature of xxx xxxxxxxxx or xxx/xxx representative

- Upon xxxxxxx of xxx xxxxxxxxxxx xxx the xxxxxxxxx xx financial xxxxxxx pursuant xx Xxx No. 209/1997, xxx Xxxxxxxx of Xxxxxxx xxxxx confirm xxxxxxx xxx xxxxxx xx x serial xxxxxx. Xxxxxxxxxxxx, xxx Xxxxxxxx xxxxx xxxxxxxx xx investigation xxxx xxx xxxxxx xx x similar xxxxxxxxx xx xxx the xxxxxxxx xxxxxxx xx xxx case. Xxxxxx xxxxx months from xxx date of xxx xxxxxxx of xxx application and xxxxxxxxxx xx the xxxxxxxxx xxxxxxxxx, the Xxxxxxxx xxxxx either xxxxxxx the xxxxxxx xx inform the xxxxxxxxx of the xxxxxxx xxx such xxxxxxx xxx been xxxxxxxx.

- Xxx xxxxxxxxx xxxxx xx considered x xxxxxx xx xxx Xxx Xx. 209/1997 Xxxx. only xx he/she has xxxxxxxx xxxxxx harm xx x xxxxxx xx the commitment xx a xxxxx. X necessary xxx xxx the xxxx xxxxxxxxx for xxx xxxxxx'x xxxxxxx xx xxxxxxxx support xxxxx xx xxx xxxxxx xx the point-based xxxxxxxxxx of the xxx xxxxxxxx (not xxx xxxxxxxxx of xxxxxx xxxxxxxx), xxxxx xxxx be xx xxxxx 100 xxxxxx. Xxxxxxxxx xx x xxxxxx xxx xxx xxxx xx xxxxxxxxxxx xx x xxxxx xxxxx be xxxxxxxxxx xx be a xxxxxx if the xxxxxxxx xx x xxxxxx, xxxxxx or xxxxx of the xxxxxxxx xxx xxx xxxxxxxx xxxxxx a xxxxxxxxx xxxx xxx xxxxxxxx xx xxx xxxx of xxx/xxx xxxxx or xx xxx xxxxxxxx xxxxxxxxx xx xxx xxxxxxxx xx xxxxxxx the xxxxxxxx.

- Xxx Xx. 209/1997 Xxxx. xx xxx xxxxxxxxx xx xxxxxxxxx xxxxxxx xx xxxxxxx xx xxxxxxxx xxxx xxxxxxxxxx x xxxxxxxxxx xxxx xx 1 xxxx xxxx xxx xxxx on xxxxx the xxxxxx xxxxxxx xx the xxxx xxxxxx by xxx xxxxx. If xxxx date xxxx xxx xxxxxxxx xxxx xxx xxxx xx xxx commitment xx xxx xxxxx, xxx xxxxxx xxxxx xxxxxxx xxxxxxxx xx the xxxx xx xxxxx xx/xxx xxxxxxx of xxx xxxxxxxxxxxx. Xxx Xxxxxxxx xx Justice xxxxxx meet xx xxxxxxxxxxx for the xxxxxxxxx xx xxxxxxxxx xxxxxxx xxxxxxxx xxxxxxx xxxxx xxx lapse xx xxx xxxxxxxxxxxxxx xxxxxx.

- Financial xxxxxxx xx xxxxxxx for xx x xxxxxx xxx xxx suffered xxxxxx harm as x xxxxxx of xxx xxxxxxxxxx xx x xxxxx xxx xx xx the xxxx xx x xxxx xxx xxxxxxxxx xx XXX 25,000 xx xx amount xxxxx xx xxxx xxxxxx xx the xxxxx xx xxxxxxx xxxxxxxxx as xxxxxx xx xxx xxxxxx, xxxxxxx by any xxxxxx xxxxxxxxxx xxxx xx the xxxxxx xx xxxxxxxxxxxx for xxx xxxx incurred. Xxx xxxxx xxxxxx xx xxxx xxxxxxx xxxx not xxxxxx XXX 150,000. Xx, xxxxx xxx provision xx xxxxxxx, xxx xxxxxx xxxxxx xxxx xxx xxxx suffered xxxxxxx xxx xxxxxx xxxxxxxx, xxx victim xxx xxxxxxx additional xxxxxxx up xx xxx xxxxxx xx XXX 150,000 xx xx/xxx xxxxxxx xxx xx xxxxxx xxx xxxxxxxxxxxxxx xxxxxx xx xxxx (i.e., 1 xxxx from xxx xxxx on xxxxx xxx victim xxxxxxx xx xxx xxxx xxxxxx xx the xxxxx); in xxxx xxxx, xxx amounts xxxxxxx paid xxxx xx taken xxxx xxxxxxx.

- An individual xxx xx a xxxxxxxx xx a xxxxxx xxx has xxxx xx x xxxxxx xx xxx xxxxxxxxxx xx x xxxxx (x parent, xxxxxx or child xx xxx xxxxxxxx xxxxxx in x xxxxxx xxxxxxxxx with xxx xxxxxxxx xx xxx xxxx xx xxx/xxx xxxxx xx xxxxxxxxx xx or xxxxxxxx to be xxxxxxxxx xx xxx xxxxxxxx) xxxxx be xxxxxxxx xxxx x xxxx sum xxxxxxxxx xx XXX 150,000. Xxx xxxxx amount xxxxxxxx xx xxxxxxxxx xxxxxxx xxxxx xxx xxxxxx CZK 450,000; xxxxxx xxx xxxxxx xx xxxxxxx xxxxxx xxxxx, xxx amount xxxxxxxx per xxxxxx xxxxx xx xxxxxxx xxxxxxxxxxx.

- Xxx Xx. 209/1997 Xxxx. xxxx xxx xxxxxxx the xxxxxxxxx of the xxxxxxxxx xxxxxxxxx of xxxxxxxxx xx xxxxx xxxxxxxx xxxxxxx xx xxxxxxxxxx xxxxxxxxx insurance. Xx xxxxxxx related xx xxxxxxx xxxxxxxxx, xxxxxxxxxxxx xxx xxxxxxxxx xxxxxxxx xxxxxx thus xx xxxxxxxx xx xxx insurers xxxxxxxxx xxxx xxxxxxxxx xxxxxxxxx. Xxxx xx xxxxxxxx xxxxx, in xxxx xx xxxxxxxxxxx circumstances, xxx xx application xxx the xxxxxxxxx xx xxxxxxxxx xxxxxxx xx xxxxx xxxx xxx Ministry of Xxxxxxx.

- Please xxxx xx mind xxxx xxx xxxxxxxxx xxxxxxxxx xxx xxxxxxxxxxxxx required xxx xxx xxxxxxxxxx xxxxx xxxx xx xxxxxxxx xx xxx xxxxxxxxxxx. Xx the xxxxxxxxx xxxxx xx xx xx, xxx Xxxxxxxx xx Xxxxxxx xxxxxx properly xxxxxxx xxx xxxxxxxxxxx. Xxxxxx xxx xxxxxxxxx xxxx xx deliver any xxxx xxxxxxxxx xxx xxxxxxxxxxxxx xxxx xxxxxx x supplementary deadline, xxxx fact xxx xxxxxxx a decision xx xxxxxxxx xxx xxxxxxx as per Xxx No. 209/1997 Xxxx. Xxxx xxxxx xxx, xxxxxxx, xxxxxxxxx xxx xxxxxx xx xxxxxxx application.

- Xxxxxx xxxx xx mind xxxx xxx applicant xxxxx xx xxxxxxx xx xxxxxx xxx xxxxxxxxx xxxxxx xxxxxxxx xx compensation for xxxx (xxxx xxx xxxxxxxx, insurers etc.) xx the account xx xxx Xxxxxxxx xx Xxxxxxx xx xx the xxxxxx xx xxx xxxxxxx xxxxxxxx. Xxxx obligation xxxx xxx xxxxx xx xx/xxx has xxx received xxx xxxxxxxxxxxx. Xx xx xxxxxxxxx by the xxxxxx xx an xxxxxxxxxxx, xxx Xxxxxxxx xx Justice may xxxxx xxx xxxxx'x xxxxx xx xxxxx xxx return xx xxx xxxxxxxxx support xxxxxxxx xxxxx xxx xxxxx xx xxx xxxx-xxxx xxxx, provided xxxx a xxxxxx xx justified xx xxx victim's xxxxxx xxxxxxxx, xxx xxxxx xxxxxx of xxx xxxx xxxxxxxx xxx xxx xxxxxx of xxxxxxxxxxxx xxxx xx xxx victim.

Vážený pán/pani/slečna

Ospravedlňujeme xx, že x xxxxxxxx, x ktorej xx nachádzate, xxx xxxxxx Vás obťažovať xxxxxxxxxxxx otázkami. X xxxxxx rýchleho xxxxxxxxx Xxxxx žiadosti x xxxxxxxxxxx xxxxxxxx xxxxxx xxxxxxx xxxxxxxx xxxxxxxx xxxľx xxxxxx č. 209/1997 Zb., xx xxxx xxxxxxxxx xxxxx xxxxxxxxx xxxxxxxxxx. Xxxxxxxx Xxx xx xxxxxxxxxx, ktorú xx xxxxx xxxxxx.

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X. Xxxxxx, xxxxxxx čitateľne xxxxxx xxxxx x žiadateľovi - obeti xxxxxxxxx xxxx, xxxxxx xxôxxxxxx xxxx na xxxxxx, xxxxx osobe xxxxxxxxxx xx xxxxx, ktorá x xôxxxxxx xxxxxxxxx xxxx xxxxxxx:

1. Xxxxxxxxxx:

2. Xxxx:

3. Xxxxx narodenia:

4. Xxxxxx xxxxxxxx xxxxxx:

5. Xxxxxxxxxxxxxx xxxxxx (v xxxxxxx, že xx xxxx od xxxxxx xxxxxxxx bydliska):

6. Telefón:

7. X-Xxxx:

8. Xxxxxxxxxx:

XX. Ak xxxxxxxľx xxxxxxxxx xxx xxxxx (xxxxxxxx) xx xxxxxxx xxxxxxxxx xxxxxxxxxx (xxxx. xxxxxxxx dieťa xxxxxx rodičom) alebo xx základe xxxxxx x xxxxx xxxx, xxxxxxx údaje o xxxxxxxxxx:

1. Priezvisko:

2. Meno:

3. Xxxxxxxxxxxxxx xxxxxx:

Xx xxxxxxx xx xxx xxxxx, xxxx sa doložiť xxxxxxxxxx, ktorá xxxxxxxxxx xxxxxxx. Preto k xxxxxxxx priložte xxxxx xxxxx xxxx (xxx xxxxxxxx xxxxxxxxx) xxxxx xxxxx xxxxxxx listu (x xxxxxxx zákonného xxxxxxxxxx) alebo inú xxxxxxx listinu.

III. Xx xxxxxxxľ xxxxx xxxxx xxxxxxxxx po osobe, xxxxx x dôsledku xxxxxxxxx xxxx zomrela, xxxxxxx, xxxxxx, xx xxxxx o xxxxxxx xxxxx:

1. Xxxxxxxxxx:

2. Meno:

3. Xxxxx xxxxxxxxx:

4. Xxxxx xxxxxx:

5. Xxxxxxxx xxxxxxxx:

7. Xxxxxxxxxx:

8. X xxxx xxxxxx bola xxxxxxx xxxxx x xôxxxxxx xxxxxxxxx xxxx x xxxxx žiadateľa (xxxx, xxxxx, xxxxx žijúca x xxxxxxxxx xxxxxxxxxx):

Xx xx žiadateľ xxxxxx xxxxxxxxxx po osobe, xxxxx x xôxxxxxx xxxxxxxxx xxxx xxxxxxx, x xxxxxxxx xx xxxx priložiť xxxxx xxxxxxxx xxxxx x xxxxxxx, xxxxx xxxxxxxxx xxxxxxxxxx, že umretá xxxxx xxxxxxxxxx xxxxxxxxx xxxxx alebo mala xxxxxxxxx ju vyživovať (xx xxxxxx rodič - xxxxx xôxxx x rodný xxxx xxxxx xxxxxxxxxxx xxxx x xxxxxxxxxxx povinnosti, xxx xxxxxxxx xxxxx xxxxxxxx xxxx sobášny xxxx x xxx.)

XX. Xxxxxx, xx xxxxxxx xxxxxxxx xxxxxxx xxxxx xxxxxxxxxxxxxxx pošty xxxxx xxxxxxxx xx xxxxxxx xxxx; v xxxxx xxxxxxx láskavo xxxxxxx xxxxx Xxxxx účtu.

V. Xxxxxx xxxxx, xxxx xx xxxx xxxxxxxxx x xxxxx spôsobenej xxxxxxxx činom.

Uveďte dátum xxxxxxxxx xxxxxxxxx xxxx x xx xx xxxx x škode xxx xxôxxxxxxx xxxxxxxxx xx xxxxôx, xxxxxx xxxx a ako (xxxxxxxxx z xxxxxxxxx xxxxxx - dátum xxx xxxxxxxxxx).

XX. Označte xxxxx činný v xxxxxxxx xxxxxx (xxxxxxxxx xxxxx, xxxxxx xxxxxxxxxxxxxx, xxx), ktorý naposledy xxxxx konanie x xxxxxxxx čine. Xxxxxx xx xxxxxxx xxxxxx, xxx ktorou prebieha xxxxxxxxxxxx.

Xx xxxx x xxxxxxxxxx posledné xxxxxxxxxxx xxxxxx xxxxxxx x xxxxxxxx xxxxxx, ktoré xxxx predstavu o xxx, v xxxx xxxxxx xx xxx xxxxxxxx (napr. xxxxxxxxx x xxxxxxxx trestného xxxxxxxx, xxxx xxxxxxxx, xxxxxxxx - i xxxxxxxxxxxxx), xxxxxxxx xx x xxxxxxxx.

XXX. Xxxxxx, xxxx xxôxxxxx ste xxxxxxxxx xxxxx xx xxxxxxx xxxxx xx xxxxxxxľx xxxxx inej xxxxx, xxxxx zodpovedá xx škodu.

Podľa xxxxxxxxxxx §8 xxxxxx č. 209/1997 (Xx)., peňažitá xxxxx xx xôxx xxxxxx xxxxx sa xxxxxxxx s xxxxxxxxxxxxx xx to, či xxxx využila xxxxxx xxxxxxx xxxxxxxxxxx xx xxxxxxxxxx xxxxxx xx xxxxxxx xxxxx xx xxxxxxxľx xxxxx xxxx xxxxx, xxxxx zodpovedá xx xxxxx. Tento xxx xxxxxxxxxxx, xx xxxxxxxľx xxxxxxxxx činu xxxxxxxxx.

Xxx VIII. Vyplňte, xx žiadateľ xx xxxxxxxxxx xx xxxxx, xxxxx x xôxxxxxx xxxxxxxxx xxxx zomrela.

VIII. Xxxxxx, xx ste xxxxxxx xxxxxx, xxxxx xxľxx podmienky xxxxxxx x §2 odst. 2 xxxxxx x. 209/1997 Zb., xxxxxxxx xxľxx xxôx spľňa xxxxx xxxxxxxxx, xx xx Xxx xxxxx xxxxxxxxxxx xxxxx.

1. Xxxx xxx xxxxxxx, manželom xxxxx xxxxxxxx osoby, xxxxx xxxxxxx v xôxxxxxx xxxxxxxxx činu?

2. Xxxx ste s xxxxxx xxxxxxxxx xxxx xxxx xxxxxxxxx trestného xxxx x spoločnej xxxxxxxxxx?

3. Xxxxxxxxxxx Vám xxxx trestného xxxx xxxxxx, či xxxx x tomu xxxxxxx?

4. Xxľxxxx xxxxx xxxxx xxxxxxxxxxx xxxxxxxxx 1 xx 3? Xxxxxx xxx xxxxx, xx Xxx xx xxxxx.

Xxxľx xxxxxxxxxxx §2 odst. 2 xxxxxx x. 209/1997 Zb. xx xx xxxx xxxxxxxx xxxxx xxxxxxxxx po xxxxx, xxxxx x xôxxxxxx xxxxxxxxx xxxx xxxxxxx, xx xx xxxxxxx, manželom xxxxx xxxxxxxx zomretého x xxxxxxx v xxxx xxxx smrti x xxx xxxx v xxxxxxxxxx alebo xxxxx, xxxxxx xxxxxx xxxxxxxxxx xxxxx xxx povinný xxxxxxxxxx xxxxxx.

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

XX. Xxxxxx xxxxx, xxxx xx xxxxxxxx xxxxxxxx, xxxxxxxxxx xxxx xx skončila xxxxxxxx xxxxxxxxxxx.

X. Xxxxxxx xxxxx xxxxxxxx xxxxxxxxxxx xx xxxxxx xxxx:

X xxxxxxxx xx xxxx xxxxxxxx xxxxxx ohodnotenie xx xxxxxx xxxľx xxxxxxxx č. 440/2001 Zb., ktoré xxxxxxxľ získa xx xxxxxx, xxxxx xx xxxxxxxxx. Xxxxx lekársky xxxxxxx xxxx xxxxxxxxx xxxxxx hodnotenie xxxxxxxxx xxxxxxx a xxxxxx xxxxxxxxxx xxxxxxxx xxxxxxxxxxxxx xxxxxxxxxx. Pripomíname, že xxx xxxxx zákona č. 209/1997 Zb. xx xxxxxxxxxx xxx bodové xxxxxxxxxxx xxxxxxxxx xxxxxxx. Xxxľx xxxxxxxxxxx §6 odst. 2 xxxxxx x. 209/1997 Xx. xxxxxxx xxxxxxxxx' xxxxxxx xxxxx, xx xxxxxx xxxxxxxxxxx xxxxxxxxx xxxxxxx xxxxxxxxxx xxxxxxxx 100 bodov.

XI. Xxxxxx, xx žiadate x poskytnutie peňažnej xxxxxx vo výške xxxxxxxxx xxxxxxx 25&xxxx;000.- Xx xxxxx či xxxxxxxx výšku xxxxxx xxxxxxx x nákladov xx xxxxxxxx.

Xxxľx ustanovenia §7 xxxx. 1 xxxx. x) xxxxxx x. 209/1997 Xx. xx xxxxxxx xxxxx xxxxx xxxxxxxxx xxxxxxx xxxxx xx xxxxx xxxxxxxxx xxxx 25&xxxx;000.- Xx, xxxxx xx xxxxx xxxxxxxxxxxxxx xxxxxxxxxxx xxxxxxxx xx xxxxxxxx x xxxxxx zárobku. Xx sa xxxxxxxxxx xxxxxx x xxxxxxx xxxxx xx xxxxx xxxxxxxxx xxxxxxx, xxxxxxxx xx vyplňovať body XXX. - XXX. xxxxx xxxxxxxxx.

XXX. Xxxxxxx xxxxxxx x xxxxxxxx xxxxxx:

Xxx x náklady xx lieky, xxxxxxxxxxxx xxxôxxx, náklady xx xxxxxxxxxxxxx, xxxxxxxxx xxxxxx xxxxx na xxxxx x xxxxxxxxxx xx xxxxxxxxxx, xxxxxxx náklady xx xxxxxxx, x xxx. xxx xxxxxxxxxx, xx xxxxx xxxxxxx xxxxxxxxx xxxxxxxxx. Xx xxxxxxx náklady sa xxxxx xxxxxxx, inak xx xx xxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxx xxxx xxxx xxxxxľ.

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

X žiadosti xxxxxxxx xxxxxxx, ktoré potvrdzujú xxxxxxx xxxxxxxxxxx.

X xxxxxxx, xx žiadateľ xx x xxxxxxxxxxxxxx xxxxxx, xôxxx x xxxxxxxxxx xxxxxxxxxxxxľx x priemernom xxxxxxx xxxľx §351 x nasl. zákona x. 262/2006 Xx., xxxxxxxx xxxxx, x xxxxx xxxxxxxxxx predpisov. Xx je xxxxxxxľ xxxxxx xxxxxxxxxx xxxxxxxxx xxxxxx, xxxxx xxxxxxxx xxxx napríklad opis xxxxxxxxxx xxxxxxxx priznania. Xx xxxxxxxľ xxxxxx xxxxxxxx xôxxxxxx, xxxxxxxx, xxxxx xôxx xxxxxxx xxxxxxxx xxxxxxxx xxxxxxxx, xxxx xxxxxxxxxx o xxxxx starobného dôchodku. X prípade, xx x nejakého xxxxxxxxx xôxxxx nemožno xxxxxxx xxxxxxxxx pomery xxxxxxxľx, x krajnom xxxxxxx xx xxxxx xxxxxxxx xxxxxxxxxx x nich xxxxxxx xxxxxxxxxx.

XXX. Xxxxxx xxxxx nemocenských xxxxx (xxxxxxxxxxx xôxxxxxx) x xxxx, xxxxxx ich xxxxxxxľ xxxxxx, xx xxxxxxx xx xxxxxx xxxx xx xxxxxx, xxôxxxxxxx xxxxxxxx xxxxx.

X xxxxxxxx xxxxxxxx xxxxxxxxxx xxxxxxxxxxxxľx xxxxx poisťovne x xxxxx nemocenských xxxxx. X xxxxxxx, xx v xôxxxxxx xxxxx xx xxxxxx xxôxxxxxxx xxxxxxxx činom Xxx xxxxxxxx xxxxxxxxx xôxxxxxx, xxxxxx x xxxxxxx xxxx xxxxx.

Xxxx xxxxxxxxx xxxxxx xx xxxx, že xxxxxxxx xxxxx, xxxxxxx xxx xxx(x) xxxxxx, xx moja sociálna xxxxxxxx xxxxxxxx. Xxxxx, xxxxx xx xxxxx xxôxxxxx, xxxxxľ xxxxxx xxxxxxxx.

Xxxxxx vyhlasujem, xx xxxxx xx xxxxxxx xxxxx či xxxxxxx xxxxx xx odškodnenie xxxx xxôxxxxxxx trestným xxxxx xxx xxxxxxxxxx(x) x xxxxxxx xxxx xxxxx xxx x Xxxxxx (Slovenskej) republike.

Beriem xx xxxxxxx, že xx xxxľx ust. §12 zákona x. 209/1997 Xx., o xxxxxxxxxx peňažnej xxxxxx xxxxxxx trestnej xxxxxxxx x x xxxxx x x xxxxxxxx xxxxxxxxxx xxxxxxx, x xxxxx xxxxxxxxxx xxxxxxxxx, xxxxxx xxxxxxxxx xx xxxxxxx xxxxx xxx xxx, keď xx xxxxxxxx pomoc, xxxxxxx xx účet Xxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxx, xxxxx xxx xxxxxx(x) xxx xxxxxxx xxxxx, x xx až do xxxxx xxxxxxxxxxx xxxxxx. Xxxxxxx x xxx xxxxxx na xxxxxxx, xx xx xxxxxxxx xxxxxxxxxx xäxxxxxxx xxxx xôxxx xxxxxxxx Ministerstvo xxxxxxxxxxxxxx, xxx xx x xxxx xxxxx xxxxxx xxxxx xx xxxxxxxx xxxxxxxxxxx xxxxxx, xx xxxx sociálna xxxxxxxx xxxx xxxx xxxxxx xxôxxxxxxxx, xxxxxxx xxxxx xxxxx, xxxxx xx xxôxxxxxx x xxxxx xxxxxxx, ktorú xxx xxxxxx(x).

Xxxxxx xxxx xx xxxxxxx, že xxxxxxxxx uvedením xxxxxxxxxxx xxxxx neúplného xxxxx xx xxxx zatajením xx xxxxxx xxxxxxxx xxxxxxxxxxxx výhody, xx xôxxx xxxxxxxx priestupku xxxľx §21 xxxx. 1 xxxx. c) xxxxxx č. 200/1990 Xx., o xxxxxxxxxxxx, x xxxxx xxxxxxxxxx xxxxxxxxx.

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xxxxxx xxxxxxxľx alebo xxxxxxxx

- Xxxxxxxxxxxx xxxxxxxxxxxxxx Xxxxx xxxxxxxxx xx xxxxxxx xxxxxxxx x xxxxxxxxxxx xxxxxxxx xxxxxx xxxľx xxxxxx č. 209/1997 Zb. xxxxxxx xxx xxxxxx x xxxxx xxxxxxxx xxxxx. Xxxxx bude xxxxxxxxxx na xxxxxxx xx xx xxxx xxxxxxxx orgáne xxxľx xxxxxxxxxxx xxxxxxxxx prípadu. Xx xxxxx mesiacov xx xxxxxx xxxxxxxx x xxxxxxxxxx xxxxxxxxxx xxxxxxxx xxx pomoc xxxxxxxx xxxxx xxxxxxxľxxx xxxxxx xôxxxx, xxxxx xxxxx xxxxxxx xxxxxxxx.

- X zmysle zákona č. 209/1997 Zb. bude xxxxxxxľ xxxxxxxxxx za xxxx xxx x xxxxxxx, xx xx v xôxxxxxx trestného xxxx xxxx xxôxxxxxx xxxxxxxxxx xxxxxxx. Xxxxxxxxxxx, nie xxxx xxxxxxxxxxxx xxxxxxxxxx xx xxxxxxxxx peňažnej xxxxxx takej xxxxx xx xxxxx xxxxxxxx xxxxxxxxxxx xxxxxxx (xxx xxxx sťaženie xxxxxxxxxxxxx xxxxxxxxxx) xxxxxxxxxxxx xxxxx 100 bodov. Xx xxxx xx xxxxxxxx xx xxxxx pozostalá xx xxxxx, xxxxx x xôxxxxxx trestného xxxx xxxxxxx, ak xxxx xxxxxxx, xxxxxxxx xxxxx xxxxxxxx xxxxxxxxx x xxxxxxx x xxxx jeho xxxxx x ním xxxx x xxxxxxxxxx, xxxxx xxxxx, ktorej xxxxxxx xxxxxxxxxx alebo xxx xxxxxxx poskytovať xxxxxx.

- Xxxxx č. 209/1997 Zb. o xxxxxxxxxx peňažitej xxxxxx xxxxxxx xxxxxxxx činnosti xxxxxxxxx xxxxxxxxxxx (xxxxxxxx) xxxx 1 xxxx xxx xxx, keď xx xxxx xxxxxxxxx x škode xxôxxxxxxx xxxxxxxx xxxxx. Ak xxxxx dňom už xxx xx xxx xxxxxxxxx xxxxxxxxx xxxx, xxxx dokazuje xxxxxxx, xxxx xx to xxxxx. Ministerstvo xxxxxxxxxxxxxx xxxôxx xxxxxxxx xxxxxxxxxx x xxxxxxxxxxx xxxxxxxx xxxxxx, xxxxx xx xxxxxxxx xx xxxxxxxx xxxxxxxxxx xxxxxx.

- Pomoc xx na žiadosť xxxxx, xxxxxx x xôxxxxxx xxxxxxxxx činu xxxxxxx xxxxx xx xxxxxx, xxxxxxxx x xxxxxxxxx xxxx 25 000.- Xx xxxxx xx xxxxx, xxxxx xxxxxxxxxxx xxxxxxxxxx stratu xx xxxxxxx, xxxxxxxxxx náklady xxxxxxx x liečením, xxxxxxx x xxxxx xxxxxxxx xxxxxxx, ktoré xxxx z xxxxxx xxxxxxx xxxxx xx xxxxxxx; pomoc vo xxxxxx xxxxx xxxxxx xxxxxxxxxx sumu 150 000.- Xx. Ak obeť - xx tom, xxx xxx poskytli xxxxx - xxxxxxxx, xx xxx xxxxxxxxx xxxxx xx xxxxxx xxx tá, xxxxx xxxx xxxxxxxxx xx xxxxxxxxxxx xxxxxx, na xxx žiadosť v xxxxxx stanovenej xxxxx xxxxxxx xxx možno xxxxxxxxx pomoc xxäx, x xx xx xx xxxxxxxxxx xxxxx 150&xxxx;000.- Kč; pričom xx prihliadne na xxxxxxx, xxxxx xx xxxx xxxxxxxxx.

- Fyzickej xxxxx, xxxxx xx xxxxxxxxxx xx xxxxx, xxxxx v dôsledku xxxxxxxxx xxxx zomrela (xx xxxx xxxxxxx, xxxxxxxx xxxxx xxxxxxxx xxxxxxxxx a xxxxxxx x xxxx xxxx xxxxx s xxx xxxx x xxxxxxxxxx, xxxxx jej xxxxxxx xxxxxxxxxx, xx bol xxxxxxx xxxxxxxxxx xxxxxx), xx poskytne xxxxxxx xxxxx x xxxxxxxxx xxxx 150&xxxx;000.- Kč; xxxxx xx xxxxxx xxxxx xxxxxx presiahnuť xxxx 450 000.- Xx, x ak je xxxxx xxxxx viac xxx xxx xxxxx, xxxxxxxxxxx xxxxxxx xx xxx xxxxxx xxxxx xxxxxxxxx xxxxx.

- Zákon č. 209/1997 Zb. xxxxxxxxxxxx xxxxxxxx xxxxxxxxxxx xxxxxxxxxxxxx xxxxxxxxxxľx xxxxxxxxxx xxxxxxxx, na xxxxx xxxxäxxxx povinné xxxxxxx xxxxxxxxx zodpovednosti. Xxxxx je xxxxxxxx x xxxxxxxxxxxxxx dopravných xxxôx xxxxxx subjekt, xxxxx xxxxxxxx xxxxxxxxx xxxxxxxxxxxxx, x xxxxxxxxxxx xxxxxxxxx plnenia. Len x celkom xxxxxxxxxxx xxxxxxxxx x xxxxxxxxxxxxx xx xxxxxxxxx xxxxxxxxx xxxxxxxxx xx xxxxx xxxxxx xxxxxxxxxxxx xxxxxxxxxxxxxx x poskytnutie xxxxxxxx xxxxxx.

- Pripomíname, xx xx xxxxxxxxxx xxxxxxxx xxxxxx dostupné xxxxxxx x xxxxxxxxxx, na xxxxx odkazujeme pri xxxxxxxxxxxx xxxxxxxxx. Ak xxx žiadateľ xxxxxxx, xxxxxxxxxxxx xxxxxxxxxxxxxx xxxôxx xxxxxxx žiadosť. Xx xxxxxx xxxxxxxxxx x xxxxxxx xxx xxxxxxxxx xxxxxx, xxxx xxxxxxxxxx xôxx xxx xôxxxxx xxxxxxxxxxxxx xxxxxxxx pomoci xxxľx zákona č. 209/1997 Zb. Xx však nevylučuje xxxxxxx xxxxx novú xxxxxxx.

- Upozorňujeme, xx xx xxxx xxxxxxxľxxx xxxxxxxxxx xxxxxxx xxxxx, xxxxxxxľ xx xx xxxxxxx rokov odo xxx poskytnutia xxxxxx xxxxxxx xx účet xxxxxxxxxxxx spravodlivosti sumy, xxxxx xxxxxx xxx xxxxxxx xxxxx (xx xxxxxxxľx, xxxxxxxxx x xxx.) xx xx xxxxx poskytnutej xxxxxx. Xxxx povinnosť xxxx, xx mu xxxxx xxxxxxxxxx. Xx xxxxxxx xxxxxxxx xxxxx xx xxxxxxxxxxxx xxxxxxxxxxxxxx xôxx x xxxx xxxxx xx xxxxxxxx xxxxxxxxxx xäxxxxxxx xxxx vzdať xxxxx xx xxxxxxxx xxxxxxxxxxx xxxxxxxx pomoci. Xx xxxxxx postup xxôxxxxxxx xxxxxxxx situácia xxxxx, xxxxxxx xxxxx xxxxx, xxxxx xxx xxôxxxxxx, x výška xxxxxxx, ktorú xxxx xxxxxxx.