THE NEWFOUNDLAND AND LABRADOR LEGAL AID ...I Consent to allow communication by e-mail, knowing that...
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Address: Mailing Address: Given Name: Spouse's Name: Name of Dependent: Date of Birth: Relationship: Number of Dependents (people you are financially responsible for): Living with you? Yes No Yes No Yes No Yes No Dependents: Maiden/Other: City/Town: City/Town: Province: Postal Code: Province: Postal Code: THE NEWFOUNDLAND AND LABRADOR LEGAL AID COMMISSION APPLICATION NO. _____ - _____ - ___________ (OFFICE USE ONLY) Surname: Date of Birth: SIN: Home Phone: Cell Phone: Other/Work Phone: E-mail: If yes, provide Account # (6 digits) Contact Information Mailing Address Gender: Male Female Employment Status: Employed Unemployed Student or in training Yes No Marital Status: Married Divorced Single Widowed Separated Common Law University Post Secondary Education: Highest Grade Completed Do you receive Social Assistance?: Name of Employer E.I. benefits - start & end date: Page 1 of 4 APPLICATION Date of Birth:
Transcript of THE NEWFOUNDLAND AND LABRADOR LEGAL AID ...I Consent to allow communication by e-mail, knowing that...
Address:
Mailing Address:
Given Name:
Spouse's Name:
Name of Dependent: Date of Birth: Relationship:
Number of Dependents (people you are financially responsible for):
Living with you?Yes NoYes
NoYes NoYes
No
Dependents:
Maiden/Other:City/Town:
City/Town:
Province: Postal Code:
Province: Postal Code:
THE NEWFOUNDLAND AND LABRADOR LEGAL AID COMMISSION
APPLICATION NO. _____ - _____ - ___________ (OFFICE USE ONLY)
Surname:
Date of Birth:SIN:
Home Phone:Cell Phone:Other/Work Phone:E-mail:
If yes, provide Account # (6 digits)
Contact Information
Mailing Address
Gender: Male Female
Employment Status:
EmployedUnemployedStudent or in training
Yes No
Marital Status:Married DivorcedSingle WidowedSeparated Common Law University
Post Secondary
Education:Highest Grade Completed
Do you receive Social Assistance?:
Name of EmployerE.I. benefits - start & end date:
Page 1 of 4
APPLICATION
Date of Birth:
Describe the purpose of this application or problem:
Family (divorce, separation, custody, access, etc.)CivilCriminal
Other
Employment Insurance AppealSocial Assistance AppealWorkers' Compensation Appeal
If criminal, specify charges(s), upcoming court dates, name of accused(s) and name of complainant: If other, specify:
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Have you previously consulted a lawyer on the same matter?:
If yes, provide the Name of the Lawyer:
Amount Paid: Date:
Yes No
FINANCIAL INFORMATION
LEGAL MATTER
Shelter (rent/mortgage)
House InsuranceTaxesTelephoneLight & HeatOil (if applicable)
LoansCharge Account(s)Support (i.e. child)
Car InsuranceOther
Total:
Yours SpouseSalaryOld Age Security
Social Assistance
Employment InsuranceWorker's CompensationDisability PensionCanada Pension PlanOther
Total:
Monthly (net) Income: Monthly Expenses:
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Automobile(s)
Make:
Year:
Year:
Make:
Value: Amount Owing:
Amount Owing:Value:
Personal Property:
Household furnishings, appliances Value (appraised/est.)
Statement of Liabilities:
Bank OverdraftBusiness Loans (est.)
Personal LoansMortgage (est.)
Other
Total:
Statement of Assets:
Cash on handBank AccountCredit UnionSecurities (Savings Bonds, etc.)
Other
Total:
Life Insurance:
Face ValueCash surrender
Home:
Mortgage Co.:
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.
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
Signature of Witness Signature of Applicant
day of, this , 20
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]
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