Internal Use and Utilities

Declaration and authority to obtain and disclose information

By completing this form I authorise JusticeNet SA Inc. to:

1. request, transfer and receive personal or financial information or documentation in relation to me for the purposes of assessing my eligibility for assistance; providing assistance and, obtaining feedback about the progress or outcome of a legal matter for which I have been referred for legal assistance, without waiving legal professional privilege;
2. discuss my case with, and disclose any personal or financial information or documentation to any lawyer, barrister or organisation for the purpose of assessing my eligibility for assistance and providing assistance;
3. use my personal information anonymously to compile statistical data for the purpose of evaluating JusticeNet services.

I understand that this authority continues until I withdraw it in writing.

First Name Last Name Date of birth Email Third party authorities (optional)

I authorise the following third parties to provide JusticeNet with any information and documentation they request in relation to my legal matter:

<table class="mceNonEditable finTable" style="width:100%;"> <thead> <tr> <td style="width:40%;">Name (E.g. Dr Smith)</td> <td style="width:30%">Relationship to you (E.g. My GP)</td> <td style="width:30%">Phone number</td> </tr> </thead> <tbody class="mceEditable"> <tr class="mceEditable"> <td class="mceEditable"><div></div></td> <td class="mceEditable"></td> <td class="mceEditable"></td> </tr> <tr class="mceEditable"> <td class="mceEditable"><div></div></td> <td class="mceEditable"></td> <td class="mceEditable"></td> </tr> </tbody> </table>

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