File Number

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	ACT CIVIL AND ADMINISTRATIVE TRIBUNAL

REQUEST ABOUT PAYMENT
 OF FEES

The appropriate YES or NO boxes must be marked:	[ X ].
Please use whole dollars eg: $25 not $24.65.  Income and expenses are to be calculated on a fortnightly basis.

1.	APPLICANT:

	Name:		___________________________________________________       

	Address:	______________________________________P/code:_______	

	Occupation	:__________________________________________________

I ask that payment of the fee of $_________.00  

[  ]	be deferred for a period of ______ days
	Note to applicant – now complete Section B only

[  ]	be remitted or refunded
	Note to applicant – now complete Section C only

[  ]	be waived
	Note to applicant – now complete Section A only

A.	REQUEST TO WAIVE FEE
	
2.	The Registrar must be satisfied payment of the fee would cause you hardship

	Are you currently employed?

	YES	[    ]		(if "yes", please complete this section)

	NO	[    ]		(if "no", please go to 3. OTHER INCOME)

	I am employed by:

	_______________________________________________________________

	My employer's address is:

	___________________________________________________P/Code:_____

My income after tax is $…..….00 per fortnight.

3.	OTHER INCOME:

Do you receive any other income additional to that shown above?

YES	[    ]		(if "yes", please complete this section)

NO	[    ]		(if "no", please go to 4. EXPENSES)

The details of other income I receive including any maintenance payments for myself or my children, Family Allowance, other social security or repatriation benefits, Austudy, rent or board from people living in the same premises as I do are as follows:

NATURE OF INCOME:

_______________________________________________________________	
_______________________________________________________________	
_______________________________________________________________

		          TOTAL INCOME	 (Sections 2 & 3)		
                                                
                                               $………. Per fortnight

My Pension/Benefit number is:	_________________________________

4. 	EXPENSES:

I have______ dependants. 

(if any dependants have a separate income please show amount received fortnightly after tax)

I have the following fortnightly expenses.

	Rent/Board/Mortgage:					$……….

	Credit Card/HP/Loan repayments:				$……….

	Living expenses - food, clothing etc:				$……….
		- fares, gas electricity, phone etc:			$……….

	Other	…………………………………………..
		…………………………………………..		$……….

						TOTAL EXPENSES	$……….

5.	SAVINGS:

	Do you have any savings?

	YES	[    ]		(if "yes", please complete this section)

	NO	[    ]		(if "no", please go to 6. OTHER ASSETS)

The details of my back accounts, credit union accounts, building society accounts, investment accounts etc are as follows: (please indicate joint accounts by putting [ J ] next to the account number.)

ACCOUNT NUMBER:	NAME OF INSTITUTION:	

		

6.	OTHER ASSETS:

	Do you have any other assets?

	Assets can be things like a block of land, houses, cars, boats, shares etc.

		YES	[    ]		(if "yes", please complete this section)

			NO	[    ]

The assets I have are as follows:	(If ownership of any of your assets is shared with another person show what share you have, eg: Half share in….)

DESCRIPTION OF ASSETS	
ESTIMATED NET VALUE:	

$	

$	

$	

$	

7.	OTHER DEBTS AND COMMITMENTS:

	Do you have any other debts or financial commitments not shown above?

	YES	[    ]	(if "yes", please set these out on a separate sheet and attach it)

		NO	[    ]

8.	IS THERE ANY OTHER INFORMATION ABOUT YOU OR YOUR DEPENDANTS' CIRCUMSTANCES WHICH YOU BELIEVE SHOULD BE TAKEN INTO ACCOUNT IN DECIDING YOUR REQUEST?

	YES	[    ]	(if "yes", please set these out on a separate sheet and attach it)

		NO	[    ]	(if "no", go to 9. DECLARATION)

B.	DEFERRAL OF PAYMENT OF FEE

If a payment of a fee or charge, in whole or in part, is not able to be made at the time of the request the Registrar of the ACAT may defer the payment for a period up to 14 days or longer if, in the Registrar’s opinion, it’s in the interests of justice to do so. 

Explanation of, and reasons why, Fees/Charges should be waived

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

C.	Remit or Refund of Fee
	
When it’s in the interest of justice, or the circumstances warrant, the Registrar of the ACAT may remit or refund a fee or charge in whole or in part for the performance of a function or provision of a facility or service.

Explanation of, and reasons why, Fees/Charges should be refunded

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

9.	DECLARATION:

I declare that to the best of my knowledge and belief the information set out in this application is true and that, where any estimate is given, it is given in good faith.

		Applicant's signature:	…………………………………………

		Date:			…………………………………………

	FOR TRIBUNAL USE ONLY:

The application fee to which this request relates is, pursuant to Section 15(2)(b) of the Court Procedures Act 2004,  (circle appropriate)

-	waived / not waived

-	be deferred for a period of  _____  days

-	be remitted or refunded

		……………………
		Deputy Registrar
Date:			/     /