APPLICATION FOR ASSISTANCE UNDER THE COMMONWEALTH GUIDELINES FOR LEGAL FINANCIAL ASSISTANCE

Disbursement Support Scheme

This form is to be completed by applicants seeking assistance under the
Disbursement Support Scheme.

Before Applying

The expected cost of disbursements must exceed $500 (inclusive of GST).

The Department will not make a grant of financial assistance to cover the cost of any disbursements paid before an application is made.

No assistance is available for disbursements associated with:

  • criminal matters;
  • State or Territory legal matters; or
  • overseas legal matters.

No assistance is available to persons who are receiving, or are eligible for:

  • a grant of legal financial assistance from this Department under another scheme; or
  • assistance from a Legal Aid Commission.

Instructions

The form is to be fully completed. Please type or print neatly and answer ALL questions, and include all relevant attachments.

Incomplete applications will not be assessed.

If space provided is insufficient, include additional material on a separate page and attach to the form.

Please submit this application, including scanned copies of relevant supporting documents, by email to .

If you cannot submit by email, please contact the Financial Assistance Section on
(02) 6141 4770.

Part A:Applicant Details

Surname: / Given name:
Street address:
Postcode:
Postal address (if different):
Postcode:
Phone number:
Email address:

Part B:Legal Representative Details(if applicable)

Legal representative’s name:
Name of legal representative’s firm:
Postal Address:
Postcode:
Phone number:
Email address:

Part C:Case Details

  1. Have you applied for legal aid or assistance from another body?
Yes
No
If yes, to whom did you apply?
Please attach a copy of any letter of refusal you have received.
  1. Describe the legal action to be taken
(including the details of the Commonwealth laws involved)
  1. What are the facts of the case?

  1. What are the legal questions to be decided?

  1. What are the legal arguments in support of the case?

  1. What do you stand to gain or lose from the case?
    (For example – compensation, custody/contact with children, or employment)

  1. At what stage is the case?
(if applicable – include the court name and case reference number).
  1. What is the overall cost of the case likely to be?
(include the cost of any legal representation and unpaid disbursements)
  1. If there any further information you would like to add?

Part D:Financial Details

Enter the financial details for the applicant and any ‘financially associated person’.

A ‘financially associated person’ is any person who could be expected to assist with the cost of this matter. This may include a spouse, partner, relative, or co-applicant.

Dependants

A ‘dependant’ is someone who is reliant on your income. This may include a spouse and any dependent children.

Name / Date of Birth / Relationship to you / Living with?

Occupation

Applicant / Financially associated person

Employment Status

Applicant / Financially associated person
Employed
Unemployed
Self-Employed
Not applicable / Employed
Unemployed
Self-Employed
Not applicable

If unemployed, are you in receipt of social security benefits?

Applicant / Financially associated person
Yes
No
Not applicable
/ Yes
No
Not applicable
Income before tax / Applicant / Financially associated person / Frequency
(e.g. weekly/fortnightly)
Pensions, benefits or allowances / $ / $
Income / $ / $
Child support / $ / $
Other
(please specify) / $ / $
Total / $ / $
Expenses / Applicant / Financially associated person / Frequency
(e.g. weekly/fortnightly)
Income tax / $ / $
Rent payments / $ / $
Mortgage payments / $ / $
Board payments / $ / $
Rates / $ / $
Child support payments / $ / $
Other
(please specify) / $ / $
Total / $ / $
Assets & Liabilities / Applicant / Financially associated person / Description
Home
(approximate value)
/ $ / $
Mortgage on home? / $ / $
Other real estate
(approximate value)
/ $ / $
Mortgage on real estate? / $ / $
Farm/business
(approximate value)
/ $ / $
Mortgage on farm/business? / $ / $
Motor vehicle / $ / $
Motor vehicle loan? / $ / $
Cash/savings / $ / $
Other assets
(please specify)
/ $ / $
Other liabilities
(please specify)
/ $ / $
Is there any further financial information to disclose?

Part E:Financial Documentation

Attach copies of the following documents for the applicant and any ‘financially associated person’:

Latest tax return ‘notice of assessment’.

Statements frombank or financial institution, for the latest three month period, for all accounts held.

If employed, your last three pay slips or a letter from your employer showing your weekly income and tax paid.

If unemployed, an income statement from Centrelink or Department of Veterans’ Affairs (if in receipt of benefits).

If self-employed, latest tax return ‘notice of assessment’ and financial statements for your business.

A ‘financially associated person’ is any person who could be expected to assist with the cost of this matter. This may include a spouse, partner, relative, or co-applicant.

Part F:Legal Information

Declaration:

I, ______(applicant/solicitor) declare that the information provided in this application is true and correct to the best of my knowledge and belief. I understand that it is an offence to knowingly give false and misleading information.

Confidentiality:

The fact that a person has applied for financial assistance, and all information provided in this application will be treated in confidence and will not be disclosed except:

a)where this is necessary for purposes relevant to administering the financial assistance scheme

b)in accordance with the express authority of an applicant

c)to correct the public record, or

d)where required by law.

I understand that by submitting this application that the Department may:

  • obtain information about the subject matter of this application (including a legal opinion) from other government departments or agencies, or from the applicant and their legal representatives; and
  • disclose information in the application or other information obtained from the applicantand their legal representatives to other government departments or agencies or persons for the purpose of deciding whether to authorise financial assistance.

Signed:______

Dated:______

Application Form – Disbursement Support Scheme

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