SUPREME COURT OF THE NORTHERN TERRITORY OF AUSTRALIA

APPLICATION FOR FEE WAIVER, DEFERRAL, PAYMENT BY INSTALMENT 

	WARNING
Any person who knowingly makes an untrue representation or statement is guilty of an offence punishable by imprisonment.

•	Cross boxes where applicable.  Type or print clearly.
•	Attach an extra page if you need more space for any of the details requested
•	All details requested must be completed

NOTE: Waivers and exemptions only apply to court fees and do not apply to fees to serve documents on a person
Notice to applicant 
This form is used where you are eligible for a waiver, deferral or payment by instalment of the fee on the basis that payment of it would cause you financial hardship.

Filing fees can only be waived, deferred or leave granted to make payment by instalment on the grounds of financial hardship. You will need to show that your income, day-to-day living expenses, liabilities and assets are at such a level that payment of the fee would cause you financial hardship. You must complete the Statement of Financial Position.  

In considering your application the Court is required to consider documentary evidence to support your claim. You must annex documentary evidence such as bank account statements for the last three months, Centrelink income statements, ATM receipts, proof of liabilities and any other material that may assist the Court to determine the financial capacity of the applicant.   

This application must be lodged prior to the writ or originating process being lodged. The applicant must provide a copy of the writ or originating process when lodging the fee waiver application; however this copy is not considered to be the original document for lodgement.  Once the fee waiver is determined, the originating process can be lodged for filing along with a copy of the approved fee waiver application.

In urgent circumstances where the originating process must be lodged by a certain date, the application will be dealt with differently. In circumstances where the filing is by a legal representative, the originating process will be accepted for filing only if the legal practitioner provides a letter to the Registrar confirming the urgency, specifying why it is urgent and undertaking to pay the filing fee within a short and specified time of the assessment of the fee waiver, if it is rejected by the Court.

Self-represented litigants who present with an urgent fee waiver application will be dealt with on a case by case basis.   

SUPREME COURT OF THE NORTHERN TERRITORY OF AUSTRALIA

APPLICATION FOR FEE WAIVER, DEFERRAL OR PAYMENT BY INSTALMENT & STATEMENT OF FINANCIAL POSITION

Proposed File Name: ___________________________________________________________________

__________________________________________________________________________________________

DATe: ________________________________________________________________________________

SEEKING:

 	Waiver of payment of fees in total

 	Waiver of part payment of fees 

 	Deferral of payment of fees 

 	Leave for payment of fees to be made in instalments 

A.	PERSONAL DETAILS

1.	Full name:
			
2.	Street Address: 

and/or		

Suburb: _______________________  Postcode: ____________
	
	Postal Address		

Suburb: _______________________  Postcode: ____________
	
3.	Occupation:		
	
4.	Name of Employer (if applicable)		
	
5.	Work Address (if applicable)		
	
6.	Day time contact number:

Facsimile:

Email address:	Home: ____________________  Mobile: ___________________

Work: ____________________

	
	
A. 	DETAILS OF INCOME 

1.	The details of my and my dependants’ (if any) income (including government pensions, benefits and allowances, workers' compensation, superannuation, rent, board, interest, dividends), calculated fortnightly, are as follows [if no other income, write "nil" below]:
	[Generally, dependants are persons who rely on you or on whom you rely for financial support and included spouse, de facto partner and children]

Nature of Income	My amount	My dependents’ amount	
Fortnightly pay (after tax)	$		
Workers’ compensation	$		
Superannuation received	$		
Interest on deposits/debentures	$		
Child support, spousal and child maintenance	$		
Other income (e.g. rent or board paid to you, share dividends, Government pension, benefit or allowance (please specify)
.....................................................................................	$		
TOTAL	$		

Please note you may be asked to provide documentary evidence to support your claim.

2.  	The full name of each of my dependants is: 

Full Name	Relationship to me	

		

3.	I receive financial support or a financial contribution from family and others, calculated fortnightly, as follows [if no financial support or contribution write "nil" below]:

Name of person providing support	Nature of support	Value in $ per fortnight	
		$	
		$	
TOTAL	$	

B. 	PROPERTY AND ASSETS

["Property and assets" include land, houses, money in bank accounts and other investments, cars, boats, shares, moneys owed to you, interests in a deceased estate, interests in a trust.  If any property or asset is owned jointly with someone other than a dependant, give the name of the other owner.]

4.	My property and assets (other than bank accounts) are as follows [if no assets write "nil" below]:

PROPERTY AND ASSETS	My details (my share/interest)	My dependents’ amount	
1.   Cash (not in a bank account)	$		
2.   Other investments (e.g. shares, debentures, bonds)	$		
3.   Money owed to you	$		
4.   House / Land	$		
- Market value	$			
5.   Motor Vehicle			
- Market value	$			
6.   Value of household furniture and electrical goods	$		
7.   Other assets	$		
8.   Interest in a trust, business or partnership	$		
TOTAL 	$		

5.	Money in bank, credit union, building society accounts and other financial institutions in my name or that of my dependants’

Account Name	Name of Bank	Amount in account	
		$	
		$	
		$	
	TOTAL	$	

Please remember to annex documentary evidence regarding your financial position.  

C. 	EXPENSES

6.	My estimated day-to-day living expenses (including living expenses of my dependants that are normally paid by me), calculated fortnightly, are as follows:
	
Nature of Expense	$ per fortnight	Nature of Expense	$ per fortnight	
Rent / Board		Gas/electricity/other utilities		
Mortgage repayments		Telephone		
Other loan repayments		Health care		
Council / Water rates		Child care		
Insurance premiums		Education		
Food		Other:		
Clothing		Other:		
Spouse/Child maintenance		Other:		
Travel and motor vehicle		Other:		
Total 	$	

Please note you may be asked to provide documentary evidence to support your claim.

D. 	LIABILITIES

["Liabilities" include outstanding mortgages, credit card debts, other moneys owed by you.  If any liabilities are owed jointly with someone other than a dependant, give the name of the other person.]
 [if no liabilities write "nil" below]

7.	My liabilities are as follows:

LIABILITIES	My details	My dependants’ details	
Amount owing on my mortgage	$	$	
Amount owing on car loan	$	$	
Amount owing on other loans	$	$	
Credit Card  (No. 1)			
- Amount owing	$	$	
- Limit of the card	$	$	
Credit Card  (No. 2)			
- Amount owing	$	$	
- Limit of the card	$	$	
Other, please specify
			
TOTAL amount owing	$	$	

Please note you may be asked to provide documentary evidence to support your claim.

E. 	ADDITIONAL INFORMATION 
[Please set out any other information concerning your financial position which you believe will help the Registrar decide your request for a fee waiver]

THE NORTHERN TERRITORY OF AUSTRALIA
Oaths, Affidavits and Declarations Act 2010

STATUTORY DECLARATION
_____________________

(1) Here insert name and address of person making the declaration

(2) Signature of the person making the declaration.

(3) Signature of the person before whom the declaration is made.

(4) Here insert name and contact addressor telephone number of person before whom the declaration is made, legibly written, typed or stamped.	
I, (1)...………………………………………………………………………………….

of ……………………………………………………………………………………… 

do solemnly and sincerely declare that the statements and information provided by me in the Application for Fee Waiver, Deferral or to make Payment by Instalment and Statement of Financial Position are true and correct.

And I make this declaration pursuant to the Oaths, Affidavits and Declarations Act 2010 and state that: -

1.	This declaration is true; and

2.	I know that it is an offence to make a statutory declaration that is false in any material particular.

3.	Payment of the fee would cause me financial hardship because:

Declared at                                                      the               day of                          20 

 (3) ………………………………………………………………...                                            

 (4) ………………………………………………………………...  
                                                                               
Before me, 
(5) ………………………………………………………………...  
                                                                               
THIS DECLARATION MAY BE MADE BEFORE ANY PERSON WHO HAS ATTAINED THE AGE OF (18) EIGHTEEN YEARS.

NOTE:- A person wilfully making a false statement in a statutory declaration is liable to a penalty of imprisonment for 3years.
.........................................................................................................................................

For Court Use Only	 

DECISION ON APPLICATION FOR FEE WAIVER, DEFERRAL OR PAYMENT BY INSTALMENT

Decision on claim for waiver, deferral or payment by instalment of fees:

 	I waive payment of fees in total.

 	I waive payment of fees to the extent of …………………………………………..

 	I defer payment of fees until: 

	A.	Judgment given or completion of matter

	B.	Date payment required being: ………/….…../20……

 	I grant leave for payment of fees to be made in instalments 
	in the amount of $........................... per ……………………….…. until paid in full.

 	I do not waive, defer or grant leave for payment by instalment of fees. 
	Reason for refusal: 

		

		

		

Date:
		.................................................................................................
	Judge / Master / Registrar 
	Authorised Officer