Self-Representation Services Application Form

Court Proceedings
Which court is your matter in?

e.g. directions, status, contested

e.g. Plaintiff, Defendant, Appellant, Respondent

Time Limits
Contact Information
Contact Information
Other Contact Person

Completing this section authorises us to discuss your application with this person

Personal Information

Information will be kept confidential and used for statistical purposes only

Date of birth
Do you identify yourself as an Aboriginal or Torres Strait Islander?
What is your highest level of Education?
Referral Details
Who referred you to the JusticeNet Pro Bono Referral Service?
Legal History of your Matter
Have you applied for Legal Aid for this matter?
Have you sought assistance from a Community Legal Centre for this matter?
Have you received advice or assistance from a Private Lawyer for this matter?
About your legal matter

Please include all of the relevant facts of your matter, all important dates and what outcome you seek

List documents, letters, files, agreements, contracts, or reports which you think are relevant
Financial Circumstances – Individuals

Only to be completed by individual applicants

What is your main source of income?
Details of your income
Do you have a financially supporting person?

A financially supporting person is anyone who usually provides (or could reasonably be expected to provide) the applicant with financial support (for example, domestic partner, children or other relative, or a trust, company or partnership).

Supporting persons income
Do you have any dependants?
Do you own, or jointly own any assets?

e.g. house, cars, cash, shares

Assets
Do you have, or jointly have any liabilities?

e.g. loans, mortgages, credit cards

Liabilities

Further information about financial circumstance may be required to assess your eligibility for assistance

Financial Circumstances – Organisations

Only to be completed by organisation applicants

Is there a written funding requirement? (If yes, please provide a copy)
Funding requirement
Terms & conditions
Declaration
Terms and conditions
Date
Relevant Documents and Checklist
Have you:
Relevant documents
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