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.
Signature of Witness
Signature of Applicant
day of, this , 20
Under the authority of the Legal Aid Act, personal information may be collected for the purpose of processing and
reviewing applications for legal aid. Information that is collected is confidential and will not be disclosed without
Page 4 of 4Newfoundland and Labrador Legal Aid Commission
Any questions or comments can be directed to Michelle Wall, Applications & Financial Appeals Coordinator,
at (709) 753-7860 or firstname.lastname@example.org.