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:
Describe the purpose of this application or problem:
Family (divorce, separation, custody, access, etc.)
Civil
Criminal
Other
Employment Insurance Appeal
Social Assistance Appeal
Workers' Compensation Appeal
If criminal, specify charges(s), upcoming court dates, name
of accused(s) and name of complainant:
If other, specify:
Page 2 of 4Newfoundland and Labrador Legal Aid Commission
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 Insurance
Taxes
Telephone
Light & Heat
Oil (if applicable)
Loans
Charge Account(s)
Support (i.e. child)
Car Insurance
Other
Total:
Yours Spouse
Salary
Old Age Security
Social Assistance
Employment Insurance
Worker's Compensation
Disability Pension
Canada Pension Plan
Other
Total:
Monthly (net) Income:
Monthly Expenses:
Page 3 of 4Newfoundland and Labrador Legal Aid Commission
Automobile(s)
Make:
Year:
Year:
Make:
Value: Amount Owing:
Amount Owing:Value:
Personal Property:
Household furnishings, appliances Value (appraised/est.)
Statement of Liabilities:
Bank Overdraft
Business Loans (est.)
Personal Loans
Mortgage (est.)
Other
Total:
Statement of Assets:
Cash on hand
Bank Account
Credit Union
Securities (Savings Bonds, etc.)
Other
Total:
Life Insurance:
Face Value
Cash 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
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
authority.
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 michellewall@legalaid.nl.ca.
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