APPLICATION FOR WAIVER OF COURT FEES ON THE GROUNDS OF FINANCIAL HARDSHIP

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1 APPLICATION FOR WAIVER OF COURT FEES ON THE GROUNDS OF FINANCIAL HARDSHIP In the Court of Victoria at.. Court Ref (if any)... No... of (For office use only) B E T W E E N: Plaintiff/Applicant - and -. Defendant/Respondent Application for waiver of court fee of...for. Please note: Your completed application must be submitted with sufficient time (prior to fee s due date or statute of limitation) to allow for amendments / processing. For approval for a fee to be waived, you will need to show that your income, day-to-day living expenses, liabilities and assets are at such a level that payment of the fee would cause you financial hardship. In considering your application the Registrar/Prothonotary may ask you to provide additional documentary evidence to support your claim. In that case your application will be returned to you with instructions in the Notice of request for more information on page 9 of this document. If you are represented by a solicitor who is acting on a pro-bono basis your application for a fee waiver will generally be viewed favourably. If you are represented by a solicitor on a no win no fee basis it is highly unlikely that you will be granted a fee waiver. All represented persons who seek a fee waiver must provide a copy of the signed fee arrangement. If you are applying for a fee waiver, this form must be lodged at the same time that the proposed document is filed. A fee waiver is valid only for the fee or fees you are applying to have waived. If a further fee is payable at a later date you will need to apply again. WARNING Under the Criminal legislation any person who knowingly makes an untrue representation or statement to obtain a benefit or advantage from the State is guilty of an offence and, if found guilty, can be fined or imprisoned. 1

2 Affidavit of Financial Circumstances A Details of the individual applying for the fee waiver 1 Name family name (surname) given names Mailing Address and Daytime Phone Number post code telephone Occupation and Employment (if self-employed, please provide latest BAS Statements) occupation name of employer work address B Details of income 1. The details of my and my dependants (if any) income (including government pensions, benefits and allowances, workers' compensation, superannuation, rent, board, interest, dividends), calculated fortnightly, are as follows [if no relevant income, write "nil" in the appropriate field below]: [Generally, dependants are persons who rely on you or on whom you rely for financial support and include spouse, de facto partner and children] Nature of Income My amount My dependants amount Fortnightly pay (after tax) Government pension, benefit or allowance (please provide details and documentary evidence) Workers compensation Superannuation received Interest on deposits/debentures Child support, spousal and child maintenance Other income (eg rent or board paid to you, share dividends) TOTAL Please note you may be asked to provide additional documentary evidence to support your claim. 2

3 2. The full name of each of my dependants is: Full Name Relationship to me 3. I receive financial support or a financial contribution from family and others, calculated fortnightly, as follows [if no financial support or contribution write "nil" below]: Name of person providing support Nature of support TOTAL Value in per fortnight C Details of property and assets ["Property and assets" include land, houses, money in bank accounts and other investments, cars, boats, shares, moneys owed to you, interests in a deceased estate or interests in a trust. If any property or asset is owned jointly with someone other than a dependant, give the name of the other owner.] 4. My property and assets (other than bank accounts) are as follows [if no assets write "nil" below]: Liquid Assets My share/interest My dependants share/interest Cash (not in a bank account) Other investments (eg shares, debentures, bonds) Details: Money owed to you. Details: Sub total - liquid assets 3

4 Non-Liquid Assets My share/interest My dependants share/interest Property - House / Land - Market value - Amount of Mortgage - Net value Bank details: Motor Vehicle(s) Market value of vehicle 1 - Amount owing on vehicle - Net value Market value of vehicle 2 - Amount owing on vehicle - Net value Value of household furniture and electrical goods Other assets Interest in a trust, business or partnership Sub total non-liquid assets TOTAL of property and assets (liquid and non-liquid assets) 5. Money in bank, credit union, building society accounts and other financial institutions in my name, in my name and another persons jointly or that of my dependants Please provide bank statements for the last three weeks prior to lodging your application Account Name Name of Bank Amount in account TOTAL Do you have access to funds in any accounts other than those listed NO / YES (if yes give details overleaf) above, whether in your name or otherwise? Are you able to draw funds from any mortgage or trust fund over which you have either title or a beneficial interest? NO / YES (if yes give details overleaf) D Details of expenses 4

5 6. My day-to-day living expenses (including living expenses of my dependants that are normally paid by me), calculated fortnightly, are as follows: Nature of Expense per fortnight Nature of Expense per fortnight Rent / Board Gas/electricity/other utilities Mortgage repayments Telephone Other loan repayments Health care Council / Water rates Child care Insurance premiums Education Food Other: Clothing Other: Spouse/Child maintenance Other: Travel and motor vehicle Other: Total of Column 1 Total of Column 2 Total of Column 1 and Column 2 Please note you may be asked to provide documentary evidence to support your claim. E Details of liabilities ["Liabilities" include outstanding mortgages, credit card debts, other moneys owed by you. If any liabilities are owed jointly with someone other than a dependant, give the name of the other person.] [if no liabilities write "nil" below] 7. My liabilities are as follows: My details My dependants details Amount owing on other loans Amount owing on credit card(s) Amount owing to any businesses or individuals (please specify) Other (please specify) TOTAL amount owing Please note you may be asked to provide additional documentary evidence to support your claim. F Representation Note: all represented persons who seek a fee waiver must provide a copy of the signed fee arrangement 5

6 1. Do you have a solicitor acting for you in this matter? Yes / No 2. Is your solicitor acting on a pro-bono basis? Yes / No 3. Are you represented by a solicitor on a no win no fee basis? Yes / No 4. Do you propose to have a solicitor act for you? Yes / Maybe / No 5. If you have answered Yes or Maybe to question 4, what is the name of the firm of solicitors: 6. Are you aware that even if you are successful in this matter you may have to pay our own legal fees and any witness costs etc? Yes / No 7. Are you aware that if you are unsuccessful you will incur costs such as : witnesses, expert reports, your own legal costs and the legal costs of any other party/parties. Yes / No 8. If you have to pay, any of the costs outlined in questions 6 or 7, or any other costs, how would you pay them? G Additional information [Please set out any other information concerning your financial position which you believe will help the Registrar/ Prothonotary decide upon your application for waiver of court fees.] 6

7 H Affidavit of applicant (to be signed in the presence of the witness) 7

8 I swear/affirm (cross out incorrect one) that: 1. I am the applicant for a waiver of court fees 2. I have read this application and the details and other information attached to it 3. The facts in it that are within my personal knowledge are true 4. All other facts are true to the best of my knowledge, information and belief 5. I have disclosed all relevant financial information 6. I am aware that it is an offence to provide information or a document in connection with this application that is false or misleading Signature of Deponent:.. Affirmed / Sworn at Melbourne this.. day of.. Before me: This application was prepared by: applicant lawyer If prepared by lawyer, please provide additional information below: Name of Lawyer: Filed on behalf of: Prepared by: Solicitors Code: Telephone: DX: Ref: 8

9 (Office Use Only) NOTICE OF REQUEST FOR MORE INFORMATION Having considered your application, the Registrar/ Prothonotary requests you to provide documentary evidence of the following:... / / Signature of officer date issued 9

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