Next hearing date and time

Application for
Legal Aid
criminal legal aid

If you have any questions call 0800 2 LEGAL AID (253 425) or go to: www.justice.govt.nz/legal-aid

Personal details

1 Title Mr Ms Mrs Miss

2 Full name

3 Have you ever used another name? Yes No

If yes, your other names used:

4 Date of birth dd / mm / yyyy 5 Ethnicity

6 Your current address

Postcode

7 Your postal address (if different from current address, or in custody)

Postcode

8 Home phone 9 Work phone

10 Mobile phone 11 Other contact phone

Whose number is this?

12 Email

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Living arrangements and other personal details

13 Do you have a partner who lives with you? Yes No

If yes, your partner’s full name:

14 How many children do you have under 18 years old? (including step children, foster children etc)

How many of those are living with you?

15 Is your partner the alleged victim in the proceedings? Yes No

16 Is anyone else charged with you? Yes No

If yes, their name(s):

Are you currently subject to the Mental Health Act or the Intellectual
17 Yes No
Disability Compulsory Care & Rehabilitation Act orders?

Income

18 The income you and your partner currently receive:

Note that the following payments are excluded when we are assessing your income: Accommodation supplement, Emergency

and, if either you or your partner are in prison (excluding on remand for 3 months or less), your partner’s income and assets.

Please indicate if this income is: Before tax After tax

Frequency Frequency
You $ (eg weekly) Your partner $ (eg weekly)

Wages or salary

Employer name, phone, address:

Business/self employed

Working for families tax credits

Income from rent(s)

Interest or dividends

Income from a trust – also complete

questions 23-24

Student allowance

Other

What is your WINZ number?

You Your partner

Jobseeker support

Sole parent support

Supported living payment

NZ superannuation

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19

Assets and debts

Do you and/or your partner own or have an interest in

20 Yes No
a home or land and/or property?

Property address

Postcode

Legal owner of property

Estimated value $

Mortgage balance $

What is your share of ownership of it? (eg 50%) %

Is it in a trust? Yes No

Is it on/or Māori land? Yes No

If you and/or your partner have more than one property please provide this information on another page.

21 Do you and/or your partner have any money or investments? (excluding KiwiSaver) Yes No

You $ Your partner $

Cash, savings and term deposits

Shares and bonds

Retirement funds

Other (eg money owed to you)

Do you and/or your partner have any items that have a resale value of
22 Yes No
$3,500 or more? (eg motor vehicles, boats, other)

Description Value $ Amount owing $

23 Do you and/or your partner have any debts? Yes No

If yes, what is the balance owing? You $ Your partner $

Bank overdraft, personal debt, credit cards

Fines, tax, student loans

Hire purchase

WINZ

Other (eg Baycorp etc)

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 Only complete this section if you have an interest in a trust

24 Does the trust owe money to you and/or your partner? Yes No

If yes, how much? $

25 When will you receive this money? dd / mm / yyyy I don’t know

Please attach the original trust deed and the latest trust accounts.

Other financial information

26 Are there any other reasons why you can’t pay for your own lawyer?

Criminal charges

27 What are your charges, or the charges you are appealing?

Max. Criminal
Offence type Section and Act penalty Record Number

If you have other charges, include them on another page.

If you are facing a maximum penalty of less than 6 months in prison or are applying for parole, tick what
28
applies to you.

I have previous convictions. The proceedings involve a substantial question of law.

There is a likelihood I will go to prison if convicted. There are complex factual, legal, or evidential matters.
I do not understand the charges or cannot Other reason aid should
state my own case. be granted.

If you have ticked a statement above, provide comment on why aid should be granted.

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 Parole only

29 What are the parole proceedings about?

Postponement order Extended supervision order

Recall Release (section 21)

Non-release order Other – section of the Act

Appeals only

30 What are you appealing?

Conviction Pre-trial ruling

Sentence Parole Board matter

Conviction and sentence Other

31 What are the grounds for the appeal, and why should legal aid be granted?

Court details

32 Where will your case be heard?

Location (town, city) Court type (eg District Court) Type of hearing (eg case review)

Complete question 33 if you are applying for appeal or parole proceedings, you are facing charges that have a maximum sentence
of more than 10 years in prison or you were advised by a Police Detention Legal Assistance (PDLA) lawyer.

33 Who do you want as your lawyer?

Name My PDLA lawyer I don’t know

Please sign here

you want to choose this lawyer:

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 Applicant confirmation

By signing this application form, you agree and acknowledge that:

» personal information about you will be collected and/or disclosed to meet responsibilities under the Legal Services Act 2011, associated regulations
and/or any other relevant statute or court order. This information may be used for statistical and/or research purposes and in this context will not
individually identify you

» you have the right to have access to all information held about you, and to request correction of that information under the Privacy Act 2020

» we will assess your financial means and you may be required to repay some or all of your legal aid. Any assets or property that you own may be
subject to a charge to cover some or the entire repayment amount

» if you receive or keep any assets, property or money from your case, they are also subject to a charge to cover some or all of your legal aid costs

» if you don’t meet your repayment obligations we may issue a deduction notice to automatically deduct payments from your benefit, employment
income or bank account and/or send your debt to a third party debt collection agency with collection costs added to the amount owed

» you must let us know immediately of changes in your address, income or assets and provide updated information about your financial means
during your case

» we may contact Work and Income or another third party to obtain verification of your financial means, income, bank account, employer, address and
phone number. This could include information about your benefit and asking other third parties (including your employer, bank or other income
source) to provide the information when asked

» if you don’t provide all the information requested, your application may be declined

» your information will be saved/stored in an electronic and/or physical form

» the information you have given in this application is true, not misleading, and completed to the best of your knowledge

» it is an offence to produce false documents, not answer required questions or provide false/misleading information to obtain legal aid or avoid
repayment

» you have no insurance or indemnification available to cover some or all of your legal costs

» we will provide the contact details of your lawyer to the Police Prosecution Service and/or the Department of Corrections so that your lawyer can
receive disclosure and for their offices to be the address for service of any documents on your behalf to progress your case

» you consent to having your details provided to the court, and receiving text messages from the court about the date and time of your appearances.
If you wish to stop receiving these text messages you can reply ‘STP’. If your number changes call 0800 268 787 or talk to a staff member at your local
court.

» If a lawyer is signing this application where the applicant appeared via audio visual link, the applicant has consented to me signing this form
on their behalf; though I am not signing as agent for the applicant, nor do I provide any undertakings. I confirm this is a correct record of the
information provided to me by the applicant today.

Signature of applicant/representative Date dd / mm / yyyy

Has this application been signed or completed by a duty lawyer or someone

Yes No
other than the applicant?

Name Relationship

More information
If you have any questions call 0800 2 LEGAL AID (253 425) or go to: www.justice.govt.nz/legal-aid

You can email the completed form to: Or post it to:

» [email protected] » Legal Aid Services
» [email protected] SX10146, Wellington
» Legal Aid Services
BX10660, Auckland

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