against a decision of a court or tribunal? q Yes q No
Which Court or tribunal made the decision? .........................................
Where is the court (location) ..................................................................
What was the date of the last decision? .................................................
I ........................................................................................................................
of (address) ....................................................................................................
acknowledge that my application for legal aid will be prejudiced if I l Fail to provide information required of me and which is relevant to my application for legal aid. l Provide a document in connection with this application which is false. l Make a false or misleading statement either orally or in writing in relation to this application for legal aid.
I therefore declare that all the information I have given is true and correct to the best of my knowledge.
Applicant's signature .................................................................................
Date .................................... /..................................../ ................................ Advocate's certification (Applicable only where the application is filled by an advocate /lawyer on behalf of an applicant who cannot read or write.)
I (name of advocate/lawyer ............................................................................... Certify that I have assisted the applicant to fill this application form. Prior to the applicant appending his/her signature, I read over and explained all the contents of the application to the applicant.
Signature of Advocate/Lawyer
Date .............................../ .............................. / .............
Legal aid provider's assessment notes
Cross Reference The Advocates (Professional Conduct) Regulations, S.I 267-2
JUSTICE J.W.N TSEKOOKO, Chairperson, Law Council.