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Apply for help with fees (Mediation First)

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Apply for help with fees
You may not have to pay a court or tribunal fee, or you may get some money o.
gov.uk/help-with-court-fees
Case, claim or ‘notice to
pay’ number - Find this
number on letters from
the court or tribunal.
Complete this form using
CAPITAL LETTERS.
The information you
provide will act as
evidence to support your
application. We’ll contact
you if we need to see
additional evidence.
No
Yes, the case, claim or ‘notice to pay’ number is
4. Do you have a case, claim or ‘notice to pay’ number?
Title
First and middle names
Last name
Date of birth
National Insurance number
1. Your personal details
3. About your application
Reference (office use only)
Form name or number
- eg ‘N1’ or ‘notice to
appeal’ form.
Enter the form name or number related to this application
EX160 Apply for help with fees (06.16) © Crown copyright 2016
Your status - If your
case is against your
partner, such as a divorce,
dissolution or domestic
violence, tick single.
Single
Married or living with someone and sharing an income
2. What is your status?
No
Yes, the name of the deceased is
Date of death
5. Are you paying a fee for a probate case?
Probate - These cases
are usually about the
property and belongings
of someone who has died.
Reset form
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Savings - Include all
savings and investments,
eg ISAs.
If you have more than
£16,000 then you won’t
be able to get help with
your fees. See page 6 of
the guide.
Less than £3,000 go to question 9
More than £3,000 go to question 8
7. How much do you have in savings and investments?
(including your partner if you have one)
No. How much do you have in savings and investments?
(including your partner if you have one)
£
Yes. How much do you have in savings and investments?
(including your partner if you have one)
Less than £16,000
£16,000 or more
8. Are you (or your partner) 61 or over?
9. Do you receive any of the benets listed below?
Benets - If you’re
receiving any of these
benefits, you’re likely to
get help with your fees.
We’ll contact the
Department for Work and
Pensions to confirm that
you are (or were) getting
one of these benefits.
•
Income-based Jobseeker’s Allowance (JSA)
•
Income-related Employment and Support Allowance (ESA)
•
Income Support
• Universal Credit (and you’re earning less than £6,000 a year)
•
Pension Credit (guarantee credit)
•
Scottish Civil Legal Aid
(not Advice and Assistance or Advice by Way of Representation)
No go to question 10
Yes go to question 12
Refunds - You can apply
for a refund for a fee paid
in the last 3 months.
If you’re applying for a
refund, answer questions
7 to 11 about your
circumstances at the
time you paid the fee and
include proof of payment.
No
Yes, the fee was paid on
6. Have you already paid the fee?
Single Part of a couple
Maximum
income
£1,085 plus £245 for
each child you have
£1,245 plus £245 for
each child you have
For example:
1 child £1,330 £1,490
2 children £1,575 £1,735
Your
monthly income
Your partner’s
monthly income
Wages (before tax and National Insurance deductions)
£ £
Child Benet
£ £
Working Tax Credit
£ £
Child Tax Credit
£ £
Maintenance payments
£ £
Contribution-based Jobseekers Allowance (JSA)
£ £
Contribution-based Employment and Support Allowance (ESA)
£ £
Universal Credit (and you are earning more than £6,000 a year)
£ £
Pensions (state, work and private)
£ £
Rent from anyone living with you
£ £
Rent from other properties you own
£ £
Other monthly income:
£ £
Total monthly income
£ £
Some benefits shouldn’t be included - eg Carer’s Allowance,
Housing Benefit or childcare element of Working Tax Credit.
See full list on page 10 of the guide.
10. Do you have any children living with you, or who you support nancially?
(up to 19 years old in full-time education)
11. What is your total monthly income, before tax and National Insurance?
(including your partner if you have one)
No
Yes, children
Total monthly income - You may not get a
full fee reduction if your (and your partner’s)
monthly income is more than the amount in
the table on the right. You may be asked to
provide additional evidence of your income.
For more information see pages 11–12 of the
guide.
Address
Postcode
Email
Phone
12. Your contact details
13. Declaration and statement of truth
Return your
completed form to
the court or tribunal
handling your case
or claim.
Find contact details
for all courts and
tribunals at: gov.uk/
nd-court-tribunal
For employment
tribunal case or claim
please refer to the
EX160A guidance at
hmctsformnder.justice.
gov.uk
Please make sure you
have completed all the
relevant questions and
signed the declaration.
I believe the information I have given in this form is true to the best of my
knowledge. If I am found to have been deliberately untruthful or dishonest,
criminal proceedings for fraud can be brought against me.
I understand that if I have given false information or I do not provide further
evidence if requested, my application may be rejected and the full fee will
be payable.
Full name
Signature Date signed
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Apply for help with fees (Mediation First)

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Completed 9 August 2021

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