Application Form Please note this is not an e-mail form. It may be printed and sent to the Legal Aid's Head Office.PO Box K847 Haymarket NSW 1238. . Complete all questions on the form and provide us with the financial information where asked. 1 For what type of problem do you need Legal Aid? Family  Criminal  Civil/General  2 When is the next court date (if you know)?  3 Given names  Family name  4 Title Mr Ms  Mrs  Miss  Other  Give details:  5 Do you use or have you used other names? NoGo to question 6 Yes  Please give other name:  6 Your sex Male Female  Not applicable (For example, a group or organisation) 7 Your date of birth  8 Your home address (even if you are in custody) Postcode  Should we send mail to you at your home address? No Where can we send mail to you? Postcode  Yes Go to question 9 9 Your phone numbers Home  Work  Other contact number   10 Have you applied for legal aid before? No Go to question 11 Yes  What year?  11 Is this application being made for someone else? No Go to question 12 Yes Is it for: Separate representative Child in criminal matter Child in welfare matter Mental health matter Next friend Request by Court/Tribunal Other  Give details:  Please tell us your details so we can contact you about this application: Name  Address  Postcode  Telephone 12 Are you in custody or detention? No Go to question 13 Yes   Where?Gaol/centre  Section  Prisoner's Identification Number  13 Were you born overseas? No Go to question 14 Yes Give details: What country were you born in?  What year did you arrive in Australia?  14 Do you speak a language other than English at home? No  Go to question 15 Yes   Which language?  Do you need an interpreter? No  Go to question 15 Yes   Which language? 15 Are you an Aboriginal or Torres Strait Islander? No  Go to question 16 Yes  Go to question 16 16 Do you get Austudy or Abstudy? No  Go to question 17 Yes  Go to question 17 17 Are you a full-time member or ex-member of the Australian Defence Services or a dependant of one? No  Go to question 18 Yes  Go to question 18 18 What are your living arrangements? Married   Married but separated   Divorced   Living in a defacto relationship   Widowed   Living with other partner   Never married   Defacto but separated   Other  Give details:  19 List your dependants, include spouse/defacto/partner/children Then go to question 20 Given names Surname or family name Date of birth Relationship to you Who do they live with? Means Test - Income and Assets The term 'financially associated person' is used in this form. This term includes any person: • From whom you usually receive financial support. • Who could reasonably be expected to financially assist you in obtaining legal services. A financially associated person may include a relative, partner, spouse, trust, corporation, group. 20 Do you get a pension or benefit? No  Go to question 21 Yes  Which one? Age  Sole Parent  Disability  Unemployment  Widow  Veterans  Sickness  Special  Other  Give details:  21 How much do you or any financially associated person get from any pension, benefits or allowance? Do not include Family Payment or Child Disability Allowance. Your weekly amount  Other person's weekly amount $ $ $ $ You must give us copies of the Pension or Health Care Cards. 22 Are you employed? No   When did you last do paid work?  Go to question 23 Yes   Go to question 23 23 What work do you usually do?  24 Do you or a financially associated person receive a wage or salary? No  Go to question 25 Yes  Please give amount of income per week:   Your income  Other person’s income Gross wage $ $ Tax inc. Medicare $ $ You must give us copies of recent payslips or letters from employers setting out weekly income and tax paid. 25 Do you or a financially associated person get any other income or benefit? No  Go to question 26 Yes  Please give type of income or benefit and amount you receive weekly: Type You Other Person Rental Assistance $ per wk $ per wk Maintenance  $ per wk $ per wk Allowances  $ per wk $ per wk Commission $ per wk $ per wk Interest $ per wk $ per wk Board  $ per wk $ per wk Rent  $ per wk $ per wk Overtime $ per wk $ per wk Superannuation $ per wk $ per wk Income from trusts $ per wk $ per wk Worker’s comp. $ per wk $ per wk Other $ per wk $ per wk 26 Are you, a financially associated person or any of your dependant children : Self-employed   A primary producer (farmer,grazier)   A partner in a business  A director/shareholder in a business or company  Receiving money from a trust  Receiving any benefit from a business or company? For example, use of a car, telephone, payment of school fees.  (You may be required to provide extra information such as tax returns). None of the above Go to question 27 27 What sort of housing payments do you make or are made on your behalf by a financially associated person? Type Paid by you  Paid by other person Rent $ per wk $ per wk Mortgage  $ per wk $ per wk Board $ per wk $ per wk Rates  $ per wk $ per wk Do not pay housing costs  Give details:  28 Do you or a financially associated person pay any of the following expenses each week? No  Go to question 29 Expense You  Other person Child Care Fees  $ per wk $ per wk Spouse Maintenance  $ per wk $ per wk Loans  $ per wk $ per wk Other debts  $ per wk $ per wk 29 Do you or a financially associated person pay any child support payments or child maintenance? No  Go to question 30 Yes  Give details: Your amount per week $  Number of children payment is for  Other person’s amount per week $  Number of children payment is for  30 Do you or a financially associated person own your home in Australia or elsewhere? Including a home you are paying off No  Go to question 31 Yes  Give details: Address (if different to your home address) Postcode  How much would the home sell for? $ Mortgages or amount still owing on the home you own $ 31 Do you or a financially associated person own any other real estate in Australia or elsewhere? Including real estate you are paying off No  Go to question 32 Yes Give details: How much would it sell for? $ Mortgages or amount still owing on this property: $ Address  Postcode  32 Do you or a financially associated person own any motor vehicles? Including motor vehicles you are paying off No  Go to question 33 Yes  Give details: Your vehicles Year  Model  Market Value  Money Owing $ $ $ $ Other person's vehicles Year  Model  Market Value  Money Owing $ $ $ $ 33 Do you or a financially associated person have an account with a bank, building society or credit union in Australia or elsewhere, or have money invested with other persons? No  Go to question 34 Yes  Give details of your accounts: Your accounts Bank/building society/credit union  Amount  $ $ Other person's accounts Bank/building society/credit union  Amount  $ $   34 Do you or a financially associated person have any cash? No  Go to question 35 Yes  Give details: Your cash $  Other person's cash $ 35 Do you or a financially associated person own anything else of value in Australia or elsewhere? For example, shares, bonds, boats, caravans, jewellery, insurance or superannuation policies No  Go to question 36 Yes  Give details: Your property Item  Value $ $ Other person's property Item  Value $ $   36 Does anyone owe money to you or a financially associated person? No  Go to question 37 Yes  Give details: Money owed to you From who Amount $ $ Money owed to the other person From who Amount $ $ 37 During the last 12 months, have you or a financially associated person sold or given away any money or property in Australia or elsewhere worth more than $500? No  Go to question 38 Yes  Give details: What Date Amount $ $ $ 38 Did you or a financially associated person get any lump sum amount(s) of money greater than $500 in the last 12 months? For example, a loan, gift, compensation, redundancy, award from a court case No  Go to question 39 Yes  Give details: What  When  How much $ 39 Are you or a financially associated person likely to get any lump sum amount(s) of money in the next 12 months? Like a loan, gift, compensation, redundancy, award from a court case No  Go to question 40 Yes   What?  40 Has any person or group paid any of your legal fees for this case? No  Go to question 41 Yes  Give details: Who Amount $ 41 Can any person or group pay for your legal fees? No  Go to question 42 Yes   Who?  Details of your legal problem 42 Briefly explain your legal problem. For criminal matters—what offences are you charged with? For all matters—give details Use the last page if you do not have enough room. Please attach copies of any documents, summonses or charge sheets relating to this matter. Do not give us originals. 43 Are there current court proceedings? No  Go to question 44 Yes  Give details: When is the next court date?  Which court or tribunal do you have to appear in (for example, Family, Supreme, Administrative Appeals Tribunal?  Where is the court/tribunal? Town and State  44 Are you applying for legal aid to appeal against a decision of a court or tribunal? No  Go to question 45 Yes  Give details: Which court or tribunal made the decision?  Where is that court or tribunal? Town and state  What was the date of the original decision?  45 In respect of this application, who do you want your lawyer to be? In some cases, you may not get the lawyer you choose A Legal Aid lawyer   Name if known:  A private lawyer   Give details: Name  Firm  Address  Postcode  Telephone  No preference  Go to question 46 46 If your legal problem is: Family Law  Go to question 47 Criminal Law   Go to question 52 Civil/General Law   Go to question 55 Family Law Only 47 Provide details of the person(s) you are in dispute with Full name  Date of birth  Their address  Postcode  Their phone number  Their lawyer's name  Their lawyer's address  Postcode  48 Were you married to the person you are in dispute with? No  Go to question 49 Yes   Date of marriage  Date of separation  Date of divorce  49 Were you in a defacto relationship with the person you are in dispute with? No  Go to question 50 Yes   Date relationship started  Date of separation  50 Have you been to counselling/mediation? No  Go to question 51 Yes   Give details Name of agency   Date  51 Are there existing court orders in relation to this dispute? No  Go to question 59 Yes  Attach copies. Go to question 59 Criminal Law Only 52 Was anyone else charged with you for these offences? No  Go to question 53 Yes  Please give their names 53 Have you been committed for trial? No  Go to question 54 Yes  Go to question 54 54 Do you have any prior convictions? No  Go to question 59 Yes Give details: Year  Offence  Penalty Go to question 59 Civil or General Law Only 55 Please give the date and place where your accident or problem happened Date  Place  Go to question 56 56 Who are you in dispute with? Please give details if known Name  Address  Postcode  57 Are you insured against any part of this claim/loss? No  Go to question 58 Yes  Give details: Name of insurer  Address of insurer  Postcode  58 Can you estimate the amount of your claim/loss? No  Go to question 59 Yes Amount $ Go to question 59 Your Declaration 59 All applicants must sign the Declaration. I (name):  of (address):  Postcode  acknowledge that it is an offence to: • Fail to provide information required of me and which is relevant to this application for legal aid. • Provide a document to the Commission in connection with this application for legal aid that is false or misleading. • Make a false or misleading statement either orally or in writing in relation to this application for legal aid. I therefore declare that all the information I have given is true and correct. Applicant's (Your) Signature  Date  Solicitor's Certificate NOTE: If this application is made through a solicitor, this certificate MUST be completed. If not, it may be interpreted as an expression of opinion that the application has no merit. I (name):  of the firm of:  of (address):  Postcode CERTIFY that the applicant has consulted me and I am of the opinion that this application has legal merit and/or is otherwise deserving of aid. Solicitor's Signature  Date  You have now completed your application for legal aid. • Send the actual application form to Legal Aid. Important : ensure that all relevant material such as means verification is attached to the application

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The information contained on this page is not legal advice. If you have a legal problem you should talk to a lawyer before making a decision about what to do. The information on this page is written for people resident in, or affected by, the laws of New South Wales, Australia only.