Form 2 - Appeal Costs Fund Regulation 2010

Form 2

Appeal Costs Fund Regulation 2010

In the matter of the Appeal Costs Fund Act 1973

and

In the matter of an appeal between

(name of appellant)

and

(name of respondent)

APPLICATION TO THE APPEAL COSTS BOARD BY THE RESPONDENT FOR A CERTIFICATE AUTHORISING PAYMENT FROM THE APPEAL COSTS FUND PURSUANT TO SECTION 16(1) OF THE ACT

I, _____________________ , of ___________________________ , in the State of _____________ , (occupation), being the abovenamed respondent, hereby apply to the Appeal Costs Board for a certificate for payment to me from the Appeal Costs Fund for the following amounts:

(Set out in numbered paragraphs each amount claimed, including dollar figures and whether it is claimed as appellant’s costs of the appeal or as the case may be)

An indemnity certificate was granted to the abovenamed respondent in respect of the abovenamed appeal by the (name of Court) on the ______________ day of ________, in the year _______ .

All the facts, on which this application is made, are set out in the sworn evidence of (name of person providing sworn evidence) sworn on the _________________ day of _________, in the year _______ .

The following documents are lodged with this application:

(List all documents lodged in support of application pursuant to section 5 of the regulation)

Dated the _________________ day of _________, in the year _______ .

(Signature of applicant)

Form 2 Version 2