LEGAL LANGUAGE SERVICES
CONVENTION ON INTERNATIONAL ACCESS TO JUSTICE
(Concluded October 25, 1980)
ANNEX TO THE CONVENTION
form for transmission of application for legal aid Convention on International Access to Justice, signed at The Hague, the 25th of October 1980.
Identity and address of the transmitting authority |
Address of the receiving Central Authority |
The undersigned transmitting authority has the honour to transmit to the receiving Central Authority the attached application for legal aid and its annex (statement concerning the applicant's financial circumstances), for the purpose of Chapter I of the above-mentioned Convention.
Remarks concerning the application and the statement, if any:
Other remarks, if any:
Done at . . . . . . . . . . . . . ., the . . . . . . .
Signature and/or stamp
FORM ATTACHED TO THE CONVENTION
application for legal aid Convention on International Access to Justice, signed at The Hague, the 25th of October 1980.
1 Name and address of the applicant for legal aid
2 Court of tribunal in which the proceedings have been or will be initiated (if known)
3 a) Subject-matter(s) of proceedings; amount of the claim, if applicable
b) If applicable, list of supporting documents pertinent to commenced or intended proceedings*
c) Name and address of the opposing party*
4 Any date or time-limit relating to proceedings with legal consequences for the applicant, calling for speedy handling of the application*
5 Any other relevant information*
6 Done at . . . . . . . . . , the . . . . . . . .
7 Applicant's signature
* Delete if inappropriate.
Annex to the application for legal aid
Statement concerning the applicant's financial circumstances
I Personal situation
8 name (maiden name, if applicable)
9 first name(s)
10 date and place of birth
11 nationality
12 a) habitual residence (date of commencement of the residence)
b) former habitual residence (date of commencement and termination of the residence)
13 civil status (single, married, widow(er), divorced, separated)
14 name and first name(s) of the spouse
15 names, first names and dates of birth of children dependent on the applicant
16 other persons dependent on the applicant
17 supplementary information concerning the family situation
II Financial circumstances
18 occupation
19 name and address of employer or place of exercise of occupation
20 income |
of the applicant |
of the spouse |
of the persons dependent on the applicant |
a) salary (including payments in kind) |
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b) pensions, disability pensions, alimonies, allowances, annuities |
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c) unemployment benefits |
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d) income from non-salaried occupations |
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e) income from securities and floating capital |
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f) income from real property |
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g) other sources of income |
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21 real property |
of the applicant |
of the spouse |
of the persons dependent on the applicant |
(please state value(s) and obligations) |
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22 other assets |
of the applicant |
of the spouse |
of the persons dependent on the applicant |
(securities, sharings in profits, claims, bank accounts, business capital, etc.) |
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23 debts and other financial obligations |
of the applicant |
of the spouse |
of the persons dependent on the applicant |
a) loans (state nature, balance to be paid and annual/monthly repayments) |
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b) maintenance obligations (state monthly payments) |
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c) house rent (including costs of heating, electricity, gas and water) |
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d) other recurring obligations |
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24 income tax and social security contributions for the previous year
25 remarks of the applicant
26 if applicable, list of supporting documents
27 The undersigned, being fully aware of the penalties provided by law for the making of a false statement, declares that the above statement is complete and correct.
28 Done at . . . . . . . . . . . . . . (place) 29 the . . . . . . . . . . . . . . . . . . . . . . . (date)
30 . . . . . . . . . . . . . . . . . . . . . . . . . (applicant's signature)
