Form

1. Contact data of the entity settling the dispute

IMPORTANT: after completing the form, at the end of the application process, the form will have to be printed, signed, scanned and a scan attached as a necessary stage of completing the application process. When one year has passed since the date on which the flight subject to the application was operated or was to be operated, the application is not considered

1.1. The entity to which the application is addressed: Passengers’ Rights Ombudsman
The Passengers’ Rights Ombudsman deals with resolving civil law disputes concerning pecuniary claims arising from the provisions of the Regulation No 261/2004/EC or the Regulation No 2111/2005/EC. Proceedings at the Passengers’ Rights Ombudsman, concerning disputes arising from the Regulation No 261/2004/EC are related to flights from airports located on the territory of the Republic of Poland serviced by the EU air carriers as well as flights from third countries to these airports serviced by the EU air carriers.

1.2. Full postal address: ul. Marcina Flisa 2, 02-247 Warsaw, Poland

2. Designation of the parties

2.1. Name and surname of the applicant:

2.2. Applicant’s address of residence:

Street

House number

Apartment number

post code

town/city

2.3. Correspondence address (if different than the one given above):

The same as indicated above

Street

House number

Apartment number

post code

town/city

2.4. E-mail address (remember to agree to the consent to the delivery of letters and exchange information with the use of electronic means of communication) 2.5. Pnone (optional)2.6. How many passengers does the application concern: (The application may concern several passengers if they jointly submit the application, the complaint concerns the same flight and they have a common interest in the dispute resolution)

2.7. Entrepreneur’s name (e.g. an air carrier) with which passengers are in a dispute:

2.8. Flight no. (a separate application must be submitted for each disrupted flight)

2.10. Date of the flight

2.9. Reservation no. (fill olny if no flight number)

2.11. Departure airport

2.12. Arrival airport

2.13. Scheduled time of the departure

2.14. Actual time of the departure

2.15. Scheduled time of the arrival

2.16. Actual time of the arrival

2.17. Transit airports (if applicable)2.18. Airport / airports where the event took place Proceedings concerning disputes arising from the Regulation No 261/2004/EC are related to flights from airports located on the territory of the Republic of Poland serviced by the EU air carriers as well as flights from third countries to these airports serviced by the EU air carriers.

3. Type of proceedings

I request initiating the proceedings consisting in reconciliation of positions in order to resolve my dispute.

5. I was informed about the cancellation or delay of the flight:
When were you informed about the cancellation or delay?

at the airport

less than 7 days before the flight scheduled

between 7 and 14 days before the flight scheduled

more than 14 days before the flight scheduled

6. What was the reason given for the flight cancellation or delay?

7. An accurately specified demand and description of the circumstances justifying the demand
(state the proposal for solution this dispute and write what exactly happened)

8. Information on the existing passenger dispute
(describe, for example, whether you made a complaint to the carrier, what was the complaint process, whether you received a response and what was it)

9. Indicate whether the flight was directly related to economic or professional activity of the passenger/passengers

private flight

flight was directly related to the economic or professional activity

10. Attachments
(attach copies of documents confirming the information contained in the application, e.g. copies of tickets, reservation, complaint made, entrepreneur’s response to the complaint, copy of the correspondence with the entrepreneur if the application is submitted by an authorised attorney or another passenger, original or copy of the power of attorney, birth certificate in case of a minor passenger)

copy/scan/hard copy of a ticket or reservation for a given flight

Send fileStop sending

Files .pdf .doc .docx .tiff .tif .jpg

copy/scan/hard copy of a complaint

Send fileStop sending

Files .pdf .doc .docx .tiff .tif .jpg

copy/scan/hard copy of a response to a complaint

Send fileStop sending

Files .pdf .doc .docx .tiff .tif .jpg

copy/scan/hard copy of the correspondence exchanged with the entrepreneur

copy/scan/master copy of the power of attorney – also if one passenger submits the application on behalf of the other passengers

declaration concerning statutory representation

other (specify):

Send fileStop sending

Files .pdf .doc .docx .tiff .tif .jpg

11. I declare that:

I have read the Rules and regulations of the out-of-court passenger dispute resolution by the Passengers’ Rights Ombudsman at the President of the Civil Aviation Authority and I have accepted conditions thereof (https://pasazerlotniczy.ulc.gov.pl/upload/Regulaminy/REGULATIONS_ADR_ENG_1.1.2024.pdf). I know that the Ombudsman will refuse to consider a civil law dispute when the passenger’s application concerns flights other than: - flights from airports located on the territory of the Republic of Poland or - flights from third countries to airports located on the territory of the Republic of Poland serviced by Community air carriers where, determined pursuant to Article 16(1) of the Regulation (EC) No 261/2004, the competence of authority is the authority of another Member State or Switzerland, Norway, Iceland. I acknowledge that due to the large number of applications submitted to the Ombudsman, the waiting time for application consideration is extended, applications are considered in the order in receiving.

I attempted to contact the other party and sought a direct passenger dispute resolution on (e.g. the date of submitting a complaint to the carrier):

the case concerning the same claim between the same parties is not pending and it has not been already considered by other competent entity or by the court, (Remember that if in the same case you have brought an action against the entrepreneur before the court or the proceedings in the case are pending before the Ombudsman or other body authorised to amicably resolve disputes, the Ombudsman will be obliged to refuse to consider the dispute)

I consent to the delivery of letters to parties to the proceedings and exchange information between parties to the proceedings with the use of electronic means of communication (in point 2.4 indicate your e-mail address). If you file such a declaration the exchange of information between you and the entrepreneur as well as the delivery of the Ombudsman’s letters will be via electronic mail. If you do not consent, the correspondence will be sent in the paper form by registered mail.

I hereby declare that I (the applicant)and each of Passengers, on behalf of whom I am submitting this application, have been informed about the objective of and legal basis for processing my personal data by the President of the Civil Aviation Authority based, at 2 M. Flisa Street, 02-247 Warsaw, contained in the application for the initiation of proceedings before the Passenger Rights Ombudsman in order to conduct these proceedings. (link to the INFORMATION CLAUSE)

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