File Number

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	ACT CIVIL AND ADMINISTRATIVE TRIBUNAL

REQUEST TO WAIVE FEE

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:

	My name is:	_______________________________________________________________

	I live at:	________________________________________P/code:___	

	My occupation is:

	_______________________________________________________________

I ask that the application fee payable on my application to the Tribunal be waived.  I ask this because payment of the fee would cause me hardship.

2.	EMPLOYMENT:

	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:

	_________________________________________________________

	My income tax is $…………… 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. SUMMARY OF INCOME)

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:

	__________________________________	

			$………. Per fortnight

	__________________________________	

			$………. Per fortnight

	__________________________________	

			$………. Per fortnight

	__________________________________	

			$………. Per fortnight

			TOTAL					
                                                
                                               $………. Per fortnight

My Pension/Benefit number is________________________________

4.	SUMMARY OF INCOME:

	The total amount of income I receive per fortnight is as follows:

			EMPLOYMENT (from 2 above)	$.................                 			

			OTHER INCOME (from 3 above)	$.................				
TOTAL	$................

5.	EXPENSES:

I have______ dependants. 

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

I am committed to the following fortnightly expenses.

	Rent/Board/Mortgage:					$……….

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

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

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

							TOTAL	$……….

6.	SAVINGS:

	Do you have any savings?

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

	NO	[    ]		(if "no", please go to 7. 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:	

		

NOTE: interest received from these accounts should be included at 3. OTHER INCOME.

7.	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:	

$	

$	

$	

$	

8.	OTHER DEBTS AND COMMITMENTS:

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

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

		NO	[    ]

9.	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 10. DECLARATION)

10.	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, waived/not waived.

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