To the Executive Director for Legal Aid: |
1. I, of , |
(name in block letters) (permanent address in block letters) |
born on the day of , 20 , |
(occupation) |
apply for legal aid for the following purpose: |
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Please describe above briefly and clearly: |
(a) the kind of claim to be made or resisted, | | civil | | Criminal |
(b) whether Court proceedings have begun or an appeal is involved, |
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2. My opponent is of |
(name of opponent in block letters) |
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(address of opponent) |
3. The attorney-at-law I wish to act for me is |
(name of attorney in block letters) |
of . |
(address of attorney-at-law) |
4. Have you previously applied for legal aid? | | Yes | | No |
5. If you have previously applied for legal aid, please state the nature of the matter and the result, if any. |
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6. Has any attempt been made to settle the matter out of Court? | | Yes | | No |
If yes, please give details and enclose any correspondence |
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7. I understand that if legal aid is granted I may be required to make a contribution towards my costs but I shall have an opportunity to consider the terms on which legal aid will be given before making up my mind to accept. |
8. I undertake to supply any further information needed by the Board in connection with my case. |
9. Address where you can be contacted if you do not want to use the address above: |
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10. The following is a statement of my financial circumstances: |
(a) General Information of applicant: |
Full name: |
Address: |
Date of Birth: |
Occupation: |
Status: | | Single | | Married | | Divorced |
Note: If you are married, you must state the income of your spouse, unless he or she is your opponent in the case or you are living apart. |
INCOME OF APPLICANT |
(Please indicate what you receive after deduction of income tax and National Insurance contributions and state all sources of income below.) |
| Income of Applicant | Amount (EC$) |
| 1. | |
| 2. | |
| 3. | |
| 4. | |
What was your income for the last 12 months? |
(b) General Information of spouse: |
Full name: |
Address: |
Date of Birth: |
Occupation: |
INCOME OF SPOUSE: |
| | My spouse is my opponent |
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| | I live apart from my spouse |
| Income of spouse | Amount (EC$) |
| 1. | |
| 2. | |
| 3. | |
| 4. | |
What was the income of your spouse for the last 12 months? |
Please indicate any other source of income and the amount: |
| Source of income | Amount (EC$) |
| | pension | |
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| | state benefits | |
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| | rental income from another property | |
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| | maintenance payments for children | |
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| | any other money | |
DEDUCTIONS |
1. How many persons are dependent on applicant? x |
2000 |
2. How many persons are dependent on your spouse? x |
2000 |
3. Personal expenses $3,000.00 |
4. Are there any persons under the age of 18 years, not being members of your household, who you are supporting pursuant to a Court Order or otherwise (give name, age of such persons and specify the amounts actually paid annually for such support). |
1) |
2) |
3) |
5. Rent if any (subject to maximum of $1,000.00 per annum). |
$ |
(Expenditure relating to repairs/insurance included) |
Total Deductions $ |
Total Income – Total Deductions = Total Disposable Income |
$ |
CAPITAL OF APPLICANT |
1. Do you own any property besides a dwelling house owned and exclusively used by you and your family as your home assessed at an annual value of not more than $10 000.00? |
| | Yes | | No |
2. If yes, what is the annual value of that property? $ |
3. If you own any motor vehicle, what is its value? $ |
4. What amount do you have by way of savings in a personal or joint account in the following institutions? |
(a) Banks: $ |
(b) Credit unions: $ |
(c) Financial companies: $ |
5. If you own any other assets (for example shares, boat, real estate but excluding any dwellings specified in 1 above and your wearing apparel, tools of trade and household furniture and effects) please specify what asset and the value of that asset. |
| Assets | Value |
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| (b) | |
| (c) | |
| (d) | |
| Total value of assets: |
6. If you own any insurance policy, what is the total surrender value? |
$ |
Total Disposable Capital: $ |
STATEMENT OF LIABILITIES |
1. Do you have any liabilities? | | Yes | | No |
2. If yes, state below (list all liabilities e.g. outstanding mortgages, loans and any other debts). |
| Item | Balance Owing |
| 1) | |
| 2) | |
| 3) | |
| 4) | |
| 5) | |
| Total liabilities: $ |
Declaration of Applicant |
I declare that the information I have given on this form is correct and complete. |
I understand that if the information is not correct or complete, criminal or civil action may be taken against me. |
I give permission for the Legal Aid Board to make any enquiries of third parties and I authorize the third parties to give any information necessary to deal with this application. |
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| Signature | Date |
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CHILD OR VULNERABLE PERSON |
Please read carefully before completing this part. |
This part must be signed by the next friend applying on behalf of the child or vulnerable person (applicant). |
1. Name of next friend |
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2. Address for correspondence of next friend |
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3. Relationship to the applicant: |
4. If you are applying on behalf of a child, does this child receive any money on a regular basis? |
| | No | | Yes | |
| If yes, please specify the amount $ |
| (Do not include part-time earnings, holiday jobs, pocket money or any maintenance that you get for the child.) |
5. Does this child have any savings, items of value or investments totalling $2,500.00 or more or is he or she due to receive money from a trust fund or will? |
| | No | | Yes | |
| If yes, please specify the amount $ |
Declaration by next friend |
To be signed only by the next friend on behalf of a child or vulnerable person. |
I declare that as far as I know, the information I have given is true, based upon the reasonable enquiries which I have been able to make, exercising due care and diligence. |
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| (signature of next friend) | Date |
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REPRESENTATIVE, FIDUCIARY OR OFFICIAL CAPACITY |
Please read carefully before completing this part. |
This part must be signed by the person applying in a representative, fiduciary or official capacity on behalf of an aided person. |
1. Name of representative/fiduciary/official: |
2. Address for correspondence of representative/fiduciary/official |
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3. Relationship to the applicant: |
4. If you are applying on behalf of a person, does this person receive any money on a regular basis? |
| | No | | Yes | |
| If yes, please specify the amount $ |
5. Does this person have any savings, items of value or investments totalling $2,500.00 or more or is he or she due to receive money from a trust fund or will? |
| | No | | Yes | |
| If yes, please specify the amount $ |
Declaration by a person acting in a representative, fiduciary or official capacity |
To be signed only by a person applying in a representative, fiduciary or official capacity on behalf of an aided person. |
I declare that as far as I know, the information I have given is true, based upon the reasonable enquiries which I have been able to make, exercising due care and diligence. |
| Signature | Date |
| (signature of representative/ fiduciary/official) | |
This application form must be submitted to the Executive Director with all supporting documents attached and the application fee in order to facilitate the processing of your application. |
If this form must be completed. Failure to complete this form may result in the form being returned to you which could result in a delay in processing your application. |