APPLICATION FOR ASSISTANCE UNDER THE COMMONWEALTH
GUIDELINES FOR LEGAL FINANCIAL ASSISTANCE
Disbursement Support Scheme
This form is to be completed by applicants seeking assistance under the
Disbursement Support Scheme.
Before Applying
The expected cost of disbursements must exceed $500 (inclusive of GST).
The Department will not make a grant of financial assistance to cover the cost of any
disbursements paid before an application is made.
No assistance is available for disbursements associated with:
 criminal matters;
 State or Territory legal matters; or
 overseas legal matters.
No assistance is available to persons who are receiving, or are eligible for:
 a grant of legal financial assistance from this Department under another
scheme; or
 assistance from a Legal Aid Commission.
Instructions
The form is to be fully completed. Please type or print neatly and answer ALL
questions, and include all relevant attachments.
Incomplete applications will not be assessed.
If space provided is insufficient, include additional material on a separate page and
attach to the form.
Please submit this application, including scanned copies of relevant supporting
documents, by email to [email protected].
If you cannot submit by email, please contact the Financial Assistance Section on
(02) 6141 4770.
Part A:
Applicant Details
Surname:
Given name:
Street address:
Postcode:
Postal address (if different):
Postcode:
Phone number:
Email address:
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Part B:
Legal Representative Details (if applicable)
Legal representative’s name:
Name of legal representative’s firm:
Postal Address:
Postcode:
Phone number:
Email address:
Part C:
1.
Case Details
Have you applied for legal aid or assistance from another body?


Yes
No
If yes, to whom did you apply?
Please attach a copy of any letter of refusal you have received.
2.
Describe the legal action to be taken
(including the details of the Commonwealth laws involved)
3.
What are the facts of the case?
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4.
What are the legal questions to be decided?
5.
What are the legal arguments in support of the case?
6.
What do you stand to gain or lose from the case?
(For example – compensation, custody/contact with children, or employment)
7.
At what stage is the case?
(if applicable – include the court name and case reference number).
8.
What is the overall cost of the case likely to be?
(include the cost of any legal representation and unpaid disbursements)
9.
If there any further information you would like to add?
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Part D:
Financial Details
Enter the financial details for the applicant and any ‘financially associated person’.
A ‘financially associated person’ is any person who could be expected to assist with the cost
of this matter. This may include a spouse, partner, relative, or co-applicant.
Dependants
A ‘dependant’ is someone who is reliant on your income. This may include a spouse and any
dependent children.
Name
Date of Birth
Relationship to you
Living with?
Occupation
Applicant
Financially associated person
Employment Status
Applicant




Employed
Unemployed
Self-Employed
Not applicable
Financially associated person




Employed
Unemployed
Self-Employed
Not applicable
If unemployed, are you in receipt of social security benefits?
Applicant



Yes
No
Not applicable
Financially associated person



Yes
No
Not applicable
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Applicant
Financially
associated person
Pensions, benefits or
allowances
$
$
Income
$
$
Child support
$
$
Other
(please specify)
$
$
Total
$
$
Applicant
Financially
associated person
Income tax
$
$
Rent payments
$
$
Mortgage payments
$
$
Board payments
$
$
Rates
$
$
Child support payments
$
$
Other
(please specify)
$
$
Total
$
$
Income before tax
Expenses
Frequency
(e.g. weekly/fortnightly)
Frequency
(e.g. weekly/fortnightly)
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Applicant
Financially
associated person
Home
(approximate value)
$
$
Mortgage on home?
$
$
Other real estate
(approximate value)
$
$
Mortgage on real estate?
$
$
Farm/business
(approximate value)
$
$
Mortgage on
farm/business?
$
$
Motor vehicle
$
$
Motor vehicle loan?
$
$
Cash/savings
$
$
Other assets
(please specify)
$
$
Other liabilities
(please specify)
$
$
Assets & Liabilities
Description
Is there any further financial information to disclose?
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Part E:
Financial Documentation
Attach copies of the following documents for the applicant and any ‘financially associated
person’:
 Latest tax return ‘notice of assessment’.
 Statements from bank or financial institution, for the latest three month period, for
all accounts held.
 If employed, your last three pay slips or a letter from your employer showing your
weekly income and tax paid.
 If unemployed, an income statement from Centrelink or Department of Veterans’
Affairs (if in receipt of benefits).
 If self-employed, latest tax return ‘notice of assessment’ and financial statements for
your business.
A ‘financially associated person’ is any person who could be expected to assist with the cost
of this matter. This may include a spouse, partner, relative, or co-applicant.
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Part F:
Legal Information
Declaration:
I, ___________________________________ (applicant/solicitor) declare that the
information provided in this application is true and correct to the best of my knowledge and
belief. I understand that it is an offence to knowingly give false and misleading information.
Confidentiality:
The fact that a person has applied for financial assistance, and all information provided in this
application will be treated in confidence and will not be disclosed except:
a)
b)
c)
d)
where this is necessary for purposes relevant to administering the financial
assistance scheme
in accordance with the express authority of an applicant
to correct the public record, or
where required by law.
I understand that by submitting this application that the Department may:
 obtain information about the subject matter of this application (including a legal
opinion) from other government departments or agencies, or from the applicant and
their legal representatives; and
 disclose information in the application or other information obtained from the
applicant and their legal representatives to other government departments or agencies
or persons for the purpose of deciding whether to authorise financial assistance.
Signed: ___________________________________________________________________________
Dated: ___________________________________________________________________________
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