Legal Aid Online Application Step 1 of 7 14% Location:*SelectCarbonearClarenvilleCorner BrookGanderGrand Falls-WindsorHappy Valley-Goose BayLabrador WestMarystownSt. John'sStephenvillePersonal InformationLast Name:* First Name:* Alias/Maiden/Other: Date of Birth:* YYYY dash MM dash DD Gender:SelectFemaleMaleLet me type...I prefer not to sayPlease type here: Mailing Address:* Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Contact InformationHome Phone:*Cell Phone:Other/Work Phone:Email: EducationHighest Grade Completed: Other Education:SelectPost SecondaryUniversityMarital Status:SelectMarriedSingleSeparatedDivorcedWidowedCommon LawSpouse's Name: Spouse's Date of Birth: YYYY dash MM dash DD Spouse's Mailing Address: Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Number of Dependents:Select12345678(people you are financially responsible for)First DependentName Date YYYY dash MM dash DD Relationship Living with you? Yes No Second DependentName Date YYYY dash MM dash DD Relationship Living with you? Yes No Third DependentName Date YYYY dash MM dash DD Relationship Living with you? Yes No Fourth DependentName Date YYYY dash MM dash DD Relationship Living with you? Yes No Fifth DependentName Date YYYY dash MM dash DD Relationship Living with you? Yes No Sixth DependentName Date YYYY dash MM dash DD Relationship Living with you? Yes No Seventh DependentName Date YYYY dash MM dash DD Relationship Living with you? Yes No Eighth DependentName Date YYYY dash MM dash DD Relationship Living with you? Yes No Employment Status:SelectEmployed/Self-employedHomemakerRetiredStudent/TrainingUnemployedName of Employer:* Employer Mailing Address:* Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code E.I. benefits - Start Date: YYYY dash MM dash DD E.I. benefits - End Date: YYYY dash MM dash DD Do you receive Social Assistance?: Yes No If yes, provide Account #:(6 digits) Legal MatterHave you previously consulted a lawyer on the same matter?:* Yes No If yes, provide the Name of the Lawyer:* Amount Paid:*Date:* YYYY dash MM dash DD Describe the purpose of this application or problem:*SelectFamily (divorce, separation, parenting, access, etc.)CivilCriminalEmployment Insurance AppealSocial Assistance AppealWorkers' Compensation AppealOtherOther:* When is your next court date? YYYY dash MM dash DD Do you have an upcoming presentation hearing or is this matter an emergency family matter (eg. immediate danger of child being removed from the jurisdiction of the court without consent)? Yes No Financial InformationMonthly (net) IncomeYoursSalaryOld Age SecurityEmployment InsuranceWorkers CompensationDisability PensionCanada Pension PlanChild SupportBusiness IncomeStudent LoanOtherMonthly (net) Income TotalSpouseSalaryOld Age SecurityEmployment InsuranceWorkers CompensationDisability PensionCanada Pension PlanChild SupportBusiness IncomeStudent LoanOtherSpouses Monthly (net) Income Total Monthly ExpensesShelterrent/mortgageHouse InsuranceTaxesTelephoneLight & HeatOilIf applicable LoansCharge Account(s)Supporti.e. childCar InsuranceOtherMonthly Expenses Total Statement of LiabilitiesBank OverdraftBusiness Loansest.Personal LoansMortgageest.OtherLiabilities Total Statement of AssetsCash on handBank AccountCredit UnionSecuritiesSavings Bonds, etc.Household furnishings, appliances valueAppraised/est.Automobile(s)OtherAssets TotalLife InsuranceFace value:Cash surrender:HomeMortgage Company: Declaration and AuthorizationBy typing your name below and pressing submit:I Agree:* You are signing this application electronically. I Agree:* You agree that your electronic signature has the same legal validity and effect as your handwritten signature on the application, and that it has the same meaning as your handwritten signature. I Agree:* You declare that the information on this application is true and complete. I Agree:* You will notify your lawyer of any changes and you will provide any further information required. I Agree:* You consent to have the information provided investigated for verification. I Agree:* You realize you may have to contribute towards the cost of any services provided to you. I Agree:* You authorize a staff solicitor employed by the Newfoundland and Labrador Legal Aid Commission to disclose in Court the status of my application for Legal Aid assistance upon the request of any judge of the Provincial Court of Newfoundland and Labrador or justice of the Supreme Court of Newfoundland and Labrador. I Consent to allow communication by e-mail, knowing that should anyone else have access to my e-mail account, confidentiality may be compromised. I Consent for the Legal Aid Commission to contact me at a later date for feedback regarding the service I received from staff and/or solicitors of the Commission. Signature:* Please type your name in the box aboveToday’s date:* YYYY dash MM dash DD Under the authority of the Legal Aid Act, personal information may be collected for the purpose of processing and reviewing applications for legal aid. Information that is collected is confidential and will not be disclosed without authority.
