Approved in full Approved in part Not Approved □
ACT Law Courts and Tribunal
Application for waiver of court or tribunal fee

Section 15(2)(b) of the Court Procedures Act 2004 authorises the registrars of the Supreme Court and Magistrates Court to waive payment of a court fee by a person, in full or in part, where the registrar considers that payment of the fee, or part of the fee, would impose hardship on the person.
To apply for a fee waiver on grounds of hardship you must complete this form and lodge it with the relevant court.
Completing the form
(a) Type or print answers clearly.
(b) Where a yes or no answer is required you must tick the appropriate YES or
NO box [	].
(c) If there is insufficient space to provide the information requested attach extra pages to your application clearly noting the questions to which the information relates.
(d) You must answer all applicable questions in full. Use the words ‘nil’ or ‘not applicable’ when necessary and do not use strokes or dashes.
(e) By completing the next section headed Summary you need only complete those items of the form indicated.  If you do not complete the summary you must complete each item on the form.
(e) All amounts of income and payments must be expressed on a fortnightly basis. Where you receive income or make payments other than on a fortnightly basis you must calculate the fortnightly value and enter it on the form.
(f) You must swear or affirm the truth of the contents of the form by swearing or affirming the affidavit at page 8 before a justice of the peace, a lawyer or other person authorised to take affidavits in the State or Territory where you are swearing or affirming the affidavit.
(g) Providing false information is an offence for which you may be prosecuted.
Summary
By answering the questions 1 to 11 in this section you need only complete Item 1‑Applicants details; Item 2-Court and Tribunal details; Item 8‑Summary of income; Item 16 Expenses; and the item indicated where you answer ‘yes’ to a question in this summary.  

For example if you answer ‘yes’ to questions 1 and 6 and no to the remaining questions you must complete: Item 1-Applicants details, Item 2-Court and Tribunal details, Item 3‑Employment, Item 8‑Summary of income, Item 9‑Dependants and Item 16‑Expenses.  All other items would not be required to be completed.
1.	Are you employed? [  ] No [  ] Yes (if yes please complete item 3 Employment)
2.	Do you receive a government pension or benefit, including from a foreign government? [  ] No [  ] Yes (if yes please complete item 4 Pensions/benefit)
3.	Do you receive superannuation or a private or non-government pension? [  ] No [  ] Yes (if yes please complete item 5 Superannuation/private pension)
4.	Do you receive workers compensation? [  ] No [  ] Yes (if yes please complete item 6-Workers’ compensation)
5.	Do you receive income from any other source? [  ] No [  ] Yes (if yes please complete item 7-Other income)
6.	Do you have dependants? [  ] No [  ] Yes (if yes please complete item 9‑Dependants)
7.	Does anyone else contribute to payment of your household expenses? [   ] No 
[  ] Yes (if yes please complete item 10-Contributors to household and other expenses)
8.	Do you have any savings? [  ] No [  ] Yes (if yes please complete item 11‑ Savings)
9.	Do you have investments, a car or a house? [  ] No [  ] Yes (if yes please complete item 12- Assets)
10.	Do you have an interest in business, partnership or trust? [  ] No [  ] Yes (if yes please complete item 13-Business, partnership or trust interest)
11.	Do you have husband or wife or domestic partner? [  ] No [  ] If yes please complete (a) and (b):
a.	Is your husband or wife or domestic partner employed [  ] No [  ] Yes (if yes please answer item 14 Income of husband or wife or domestic partner)
b.	Does your husband or wife or domestic partner have any assets such as savings, a share in a house or land, own a motor vehicle, investments or interest in a business or trust? [  ] No [  ] Yes (if yes please complete item 15 Assets of husband or wife, domestic partner)
If you have any additional information you wish to have considered it should be included at item 17- Additional information.

Lodging the application

Once you have completed your application and sworn or affirmed the affidavit you must lodge it at the court.  Applications in respect of Supreme Court and Magistrates Court matters must be filed at the registry on the ground floor of the Magistrates Court Building Knowles Place Canberra.

Please note that you may be asked to provide documentary evidence in support of your application.

Item 1.  Applicant details

My name is

………………………………………………………………………………………………
and I live at

………………………………………………………………………………………………

My telephone numbers are:

..................................................................................................................................
My email address is: ...............................................................................................

My occupation is……………………………………… and I am ………..…years old.

Item 2.  Court and Tribunal details
(please tick appropriate box)
My matter is in the:

·	The Supreme Court	[	]

·	Magistrates Court	[	]

I ask that the fee payable by me for:
·	Filing an originating process	[	]

·	Filing an application in Proceedings	[	]

·	Filing a Bill of Costs for assessment	[	]

·	Filing Notice of Appeal	[	]

·	Setting a matter down for hearing	[	]

·	Service of Process	[	]

•	Transcript*	[	]

•	Other (Please Specify)  	

be waived as payment of the fee would cause me hardship.

*Where you are applying for waiver of the fee for a transcript the relevant court is the one where the matter was heard even if the transcript is required for an appeal or other proceeding in a different court

Item 3.  Employment
I am currently employed on a
[	] full time
[	] part-time
[	] casual basis (tick whichever is appropriate)
I am employed by#

………………………………………………………………………........................... 
and their address is

………………………………………………………………………............................ My fortnightly* income before tax is $………………
My fortnightly* income after tax is $………………
# if you have more than one employer please place details of any additional employers on a separate sheet and attach the sheet to this application
*if your income varies per fortnight please provide average fortnightly wage over the last three months

Item 4.  Pensions/benefit
The type of pension/benefit I receive is: ................................................................. I have been receiving the pension/benefit since………………………………………
My pension/benefit reference number is ………………………................................
I receive $……………….......... per fortnight which is paid into an account held with
……………………………….....................................................................................
Item 5.  Superannuation/private pension

I receive $.............................per fortnight from superannuation/private pension.
It is paid by ........................................
Item 6.  Workers’ compensation

I receive $..................per fortnight workers compensation from...........................

............................................................................................................................. 
Item 7.  Other income
I receive the following other income:
Type e.g. dividends; tips; royalties; interest, 
maintenance payments, rent, board
………………………………………………............... $ ……………….. per fortnight

………………………………………………................$ ……………….. per fortnight

………………………………………………............... $ ……………….. per fortnight

TOTAL	$ ……………….. per fortnight

Item 8.  Summary of income

The income I receive per fortnight is as follows:

Section 3	Employment	$………………..	
Section 4	Pension/benefit	$………………..	
Section 5	Workers’ compensation	$........................	
Section 6	Superannuation	$........................	
Section 7	Other Income	$………………..	
	Total	$……………….. per fortnight	
Item 9.  Dependants
I support the following dependants:

FULL NAME	RELATIONSHIP TO ME	AGE	INCOME	
…………………………...........................	………………	…….	$…………	

…………………………...........................	
………………	
…….	
$…………	

…………………………...........................	
………………	
…….	
$…………	

My dependants who don’t live with me reside at the addresses indicated below.

Name of dependant	Address where they live	

.....................................	
....................................................................................	

.....................................	
....................................................................................	

Item 10. Contributors to household and other expenses
The people below contribute to the fortnightly expenses of my household or provide me with financial assistance as indicated below.
Name	Nature of contribution	Amount per fortnight	

....................................................	
........................................	
$.................	

....................................................	
........................................	
$.................	

Item 11.  Savings

I have the following savings:
Type of institution              Name of institution             Current balance

Bank Accounts                   ……………………………   $………………………… Building Society                 ……………………………   $………………………… Credit Union                       ……………………………   $………………………… Investment Account           ……………………………   $………………………… Other                                  ……………………………   $…………………………
Item 12. Assets
(a) General 
In addition to my savings I have the following assets:      Estimated value 
Cash (not in bank or other financial institution)                   $ ………………
Investments (e.g. Shares, debentures, bonds)                    $……………….
Managed funds (including superannuation)                         $…………….....
Money owed to you                                                              $………………..
(b) House/Land (including jointly owned property)
Address of property: ............................................................................................

Market value of property:	$.........................		
Amount owing on property	$.........................		
Net value of property		$.....................................	

I own the property jointly with ..............................................................................
My share of the net value of the property is $....................................
(c) Motor Vehicles
Type of vehicle: .....................make.................................model........................... Year of manufacture: ........................................
Market value:  $............................

Amount owing on vehicle: $..............................Net Value of Vehicle: $..............
Item 13. Business, partnership or trust interest

The estimated value of my share of the trust/s, business/s or partnership/s is $...............

Item 14. Income of husband or wife or domestic partner
(a)	My husband/wife/domestic partner is employed [  ]No [  ] Yes 
My husband/wife/domestic partner receives $...................per fortnight from his/her employment.
(b)	My husband or wife or domestic partner receives $............... per fortnight income from other sources e.g. pension, superannuation, dividends, interest, gratuities, workers compensation, etc.
Item 15. Assets of husband or wife, domestic partner

(a)	Savings 
My husband/wife/domestic partner has the following savings: $......................
Item 15 is continued on the next page

(b)	House/Land
My husband/wife/domestic partner has the following interests in a house/land:

Address of property: ................................................................................................

Market value of property:	$.........................		
Amount owing on property	$.........................		
Net value of property		$.....................................	

They own the property jointly with ...........................................................................
My husband’s/wife’s/domestic partner’s share of the net value of the property is $.......................
(c)	Motor Vehicles
My husband/wife/domestic partner owns the following motor vehicle.
Type of vehicle: make.........................................model...................................... Year of manufacture: ........................................
Market value:  $....................

Amount owing on vehicle: $..............................Net Value of Vehicle: $.............
(d)	Business, partnership or trust interest

The value of my husband’s/wife’s/domestic partner’s interest in the trust, partnership or business is	$................

Item 16 expenses

I am committed to the following fortnightly expenses
Rent / Board                                            $ ……………………per fortnight Mortgage Repayments                            $ ……………………per fortnight Rates
Land                                              $…………………… per fortnight

Water                                            $ ……………………per fortnight

Living Expenses
Food                                             $…………………… per fortnight Petrol and other transport costs   $…………………… per fortnight Electricity                                      $ ……………………per fortnight Gas                                               $…………………… per fortnight Insurance premiums                     $............................. per fortnight Telephone                                    $..............................per fortnight Education                                     $..............................per fortnight Other                                              $..............................per fortnight
Hire purchase agreements                      $ ……………………per fortnight Medical expenses                                   $ ……………………per fortnight Credit card payments                              $…………………….per fortnight Personal loans                                        $ ……………………per fortnight Spouse/child Maintenance*                     $ ……………………per fortnight Other                                                       $…………………… per fortnight

TOTAL	$.……………………per fortnight

I pay spouse/child maintenance to.................................................................. of.....................................................................................................................
Item 17. Additional information

Please set out any other information concerning you financial position which you believe will help the registrar decide your application.

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AFFIDAVIT

On ............................ I ……………………………………………………………........
(date)	(full name)
of …………………………………………………………………………………............
(address)
whose occupation is: …………………………………………………………………... make an oath and say/affirm:

1.  I am the applicant for fee waiver.

2.  The facts in the application that are within my personal knowledge are true.

3.  All other facts are true to the best of my knowledge, information and belief.

4.  I have disclosed all relevant financial information.

5.  I am aware that it is an offence to provide information or a document in connection with this application that is false or misleading.
SWORN / AFFIRMED by the applicant:

at............................................................:	................................................ in the presence of:	(Signature of the Applicant)

...........................................................
(Signature)

...........................................................
(Name)
Justice of the Peace/Barrister/Solicitor/other

If the applicant has annexed any additional pages to his or her application please sign each annexed page.

OFFICE USE ONLY
Pursuant to Section 15(2)(b) of the Court Procedures Act 2004 I am satisfied that payment of the full fee payable under the Attorney General’s Fee Determination for........................................................................................................in this matter by ……………………………............... of ...….................................... in the ACT would impose hardship on him/her.
I therefore:

(a) Waive the entire fee

(b) Waive the fee in part with the applicant required to pay $

Dated this ……………….. day of …………………………. 20…..

Registrar/Deputy Registrar

Notice of Decision to refuse fee waiver in part or in full To:................................................................................................................... Of:....................................................................................................................
I do not approve your application for a waiver of fee in full for the following reasons:
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The above reasons constitute a statement of reasons for the purposes of section 18A of the Court Procedures Act 2004.

You may apply for a review of my decision by a Judge/Magistrate/the ACAT
within 28 days after you are given this statement of reasons. Date:

Registrar/Deputy Registrar