Download Part 2 - High Court of Australia

HIGH COURT OF AUSTRALIA
APPLICATION FOR PARTIAL WAIVER OF COURT FEES ON THE
GROUNDS OF FINANCIAL HARDSHIP (INDIVIDUAL)
STATEMENT OF AFFAIRS
PART 1
PERSONAL DETAILS
1.
Mr / Ms / Mrs / Miss:
2.
Family name:
(Please print clearly)
......................................................
Given names:
......................................................
What is your current residential
address?
......................................................
......................................................
......................................................
......................................................
State: ............................................
Post Code: ....................................
3.
What is your postal address?
(If it is the same as your
residential address write “As
above”.)
......................................................
......................................................
......................................................
State: ............................................
Post Code: ....................................
If you are renting or boarding,
who do you pay rent or board to?
Name: ...........................................
......................................................
Address: .......................................
......................................................
-2-
4.
Telephone numbers:
Home: ............................................
Work: .............................................
Mobile: ...........................................
5.
Email address:
6.
I am single / married / in a de facto relationship / separated.
7.
I have ……………dependant children, please list their names and
ages:
8.
......................................................
Name:
Age:
Name:
Age:
Name:
Age:
Name:
Age:
Are you employed?
YES
NO
Employer’s name:
......................................................
Employer’s address:
......................................................
......................................................
......................................................
Employer’s telephone
number:
9.
Have you ever been bankrupt?
NO
......................................................
In which state or territory?
......................................................
If so, on what date?
11.
YES
If so, in what year?
Has your bankruptcy been
discharged?
10.
......................................................
State the year of your last tax
return lodged:
Did you have a solicitor acting for
you in these proceedings in the
lower courts?
YES
NO
......................................................
......................................................
YES
NO
Name of firm: .................................
......................................................
If yes, was your previous
solicitor acting pro bono or
funded through Legal Aid?
YES
NO
-3-
PART 2
DETAILS OF FORTNIGHTLY INCOME
Show whole dollar amounts
only
Fortnightly wage / salary (after tax)
$ ....................................................
Fortnightly wage / salary of spouse
$ ....................................................
Child support received
$ ....................................................
Superannuation
$ ....................................................
Income from investments, interest or
dividends
$ ....................................................
Support payments from family
$ ....................................................
Other household income
$ ....................................................
TOTAL
DETAILS OF FORTNIGHTLY EXPENSES
(If there is insufficient space attach a separate
page)
$ ....................................................
Show whole dollar amounts
only
Fortnightly Rent / Board
$ ....................................................
Mortgage
$ ....................................................
Other loan repayments, including credit cards $ ....................................................
Food
$ ....................................................
Electricity / Gas / Water
$ ....................................................
Telephone
$ ....................................................
Council / Water Rates
$ ....................................................
Court orders
$ ....................................................
Spouse or child maintenance
$ ....................................................
Transport costs
$ ....................................................
Child care / Child education costs
$ ....................................................
Insurance
$ ....................................................
Other
$ ....................................................
Other
$ ....................................................
Other
$ ....................................................
TOTAL
$ ....................................................
-4-
PART 3
DETAILS OF ASSETS
(include details of where necessary eg. the name of
the bank an account is held with, or type of motor
vehicles)
House
Show whole dollar amounts
only
$ ....................................................
Address: .............................................
............................................................
Is the house in joint names?
YES
NO
If yes, please list the name/s:
............................................................
............................................................
Other real estate
$ ....................................................
Bank accounts
$ ....................................................
Other investments (eg shares, bonds)
$ ....................................................
Motor vehicles
$ ....................................................
Household furniture
$ ....................................................
Electrical goods
$ ....................................................
Interest in trust, business or partnership
$ ....................................................
Other (eg collections of stamps or coins, debts
owed to you)
$ ....................................................
TOTAL
DETAILS OF LIABILITIES
(include details of lender eg. the name of the bank
for a mortgage)
Amount owing on my mortgage
$ ....................................................
Show whole dollar amounts
only
$ ....................................................
Mortgage is held with: .................................
Amount owing on any other loans
Loan with ....................................................
Loan with ....................................................
$ ....................................................
$ ....................................................
Credit card with ............................................
Amount owing:
$ ....................................................
Limit of the card $ .............................
Any other debts
TOTAL
$ ....................................................
$ ....................................................
-5-
PART 4
ADDITIONAL INFORMATION
(Please set out any other information concerning your financial position which
you believe will help the Registrar decide your request for a fee waiver.)
Read over this form again. Be sure that everything you have written down is
correct to the best of your knowledge. If you have written details down on
separate sheets, attach them to this form then complete the following affidavit.
AFFIDAVIT
IN THE HIGH COURT OF AUSTRALIA
............................. OFFICE OF THE REGISTRY
200[ ]
No.
of
BETWEEN:
AND:
(Set out above the heading of the proceedings)
I, ............................................................. of .........................................................
(Full name)
(Address)
.............................................................................. make oath/affirm* and say as
(Occupation)
follows: The information set out in the preceding five pages of this form and contained in
the attachments thereto in relation to my financial circumstances is true and
correct to the best of my knowledge.
SWORN/AFFIRMED* by the deponent at
................................. this ................day
of .................................. 200[ ].
Before me:
.........................................................................
Deputy Registrar / Justice of the Peace /
Notary public / lawyer*
*delete as appropriate
...........................................................
Signature of deponent