application - Newfoundland and Labrador Legal Aid Commission

THE NEWFOUNDLAND AND LABRADOR
LEGAL AID COMMISSION
APPLICATION NO. _____ - _____ - ___________
(OFFICE USE ONLY)
APPLICATION
Mailing Address
Surname:
Maiden/Other:
Given Name:
Date of Birth:
SIN:
Gender:
Address:
City/Town:
Province:
Male
Postal Code:
Female
Spouse's Name:
Date of Birth:
Mailing Address:
Contact Information
Home Phone:
Cell Phone:
Other/Work Phone:
E-mail:
City/Town:
Province:
Postal Code:
Dependents:
Number of Dependents (people you are financially responsible for):
Name of Dependent:
Marital Status:
Married
Single
Separated
Date of Birth:
Relationship:
Living with you?
Yes
No
Yes
No
Yes
No
Yes
No
Education:
Highest Grade Completed
Divorced
Widowed
Common Law
Post Secondary
University
Employment Status:
Name of Employer
Employed
E.I. benefits - start & end date:
Unemployed
Student or in training
Do you receive Social Assistance?:
Yes
No
If yes, provide Account # (6 digits)
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LEGAL MATTER
Yes
Have you previously consulted a lawyer on the same matter?:
No
If yes, provide the Name of the Lawyer:
Amount Paid:
Date:
Describe the purpose of this application or problem:
Family (divorce, separation, custody, access, etc.)
Civil
Criminal
If criminal, specify charges(s), upcoming court dates, name
of accused(s) and name of complainant:
Employment Insurance Appeal
Social Assistance Appeal
Workers' Compensation Appeal
Other
If other, specify:
FINANCIAL INFORMATION
Monthly Expenses:
Monthly (net) Income:
Yours
Spouse
Shelter (rent/mortgage)
Salary
House Insurance
Old Age Security
Taxes
Social Assistance
Telephone
Employment Insurance
Light & Heat
Worker's Compensation
Oil (if applicable)
Disability Pension
Loans
Canada Pension Plan
Charge Account(s)
Other
Support (i.e. child)
Total:
Car Insurance
Other
Total:
Newfoundland and Labrador Legal Aid Commission
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Statement of Liabilities:
Statement of Assets:
Bank Overdraft
Cash on hand
Business Loans (est.)
Bank Account
Personal Loans
Credit Union
Mortgage (est.)
Securities (Savings Bonds, etc.)
Other
Other
Total:
Total:
Life Insurance:
Face Value
Home:
Mortgage Co.:
Cash surrender
Personal Property:
Household furnishings, appliances Value (appraised/est.)
Automobile(s)
Year:
Make:
Value:
Amount Owing:
Year:
Make:
Value:
Amount Owing:
I Consent to allow communication by e-mail, knowing that should anyone else have access to my
e-mail account, confidentiality may be compromised.
I Consent for the Legal Aid Commission to contact me at a later date for feedback regarding the
service I received from staff and/or solicitors of the Commission.
Newfoundland and Labrador Legal Aid Commission
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I DECLARE THAT, the information on this application is true and complete and I will notify my lawyer of
any changes. I will provide any further information required and I consent to have the information
provided investigated for verification. I realize I may have to contribute towards the cost of any
services provided to me.
I HEREBY AUTHORIZE a staff solicitor employed by the Newfoundland and Labrador Legal Aid
Commission to disclose in Court the status of my application for Legal Aid assistance upon the request
of any judge of the Provincial Court of Newfoundland and Labrador or justice of the Supreme Court of
Newfoundland and Labrador.
Dated at
, this
Signature of Witness
day of
, 20
Signature of Applicant
Privacy Notice
Under the authority of the Legal Aid Act, personal information is collected in order to administer the Legal Aid plan.
This information is kept confidential and handled as required by the Access to Information and Protection of Privacy
(ATIPP) Act. Any questions or comments can be directed to Donna Brophy, Administrative Coordinator, Newfoundland
and Labrador Legal Aid Commission, at (709) 753-7860 or [email protected]
Newfoundland and Labrador Legal Aid Commission
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