┌────────────────────────────────────────────────────────────────┐ │ │ │ │ │ ANNEX TO THE CONVENTION │ │ │ │ │ │ FORM FOR TRANSMISSION OF APPLICATION │ │ FOR LEGAL AID │ │ │ │ │ │ Convention on International Access to Justice, │ │ signed at The Hague, the 25th of October 1980. │ │ │ │ │ │ ┌─────────────────────────────┐ ┌────────────────────────┐ │ │ │Identity and address │ │Address of the receiving│ │ │ │of the transmitting authority│ │Central Authority │ │ │ └─────────────────────────────┘ └────────────────────────┘ │ │ │ │ The undersigned transmitting authority has the honour to │ │ transmit to the receiving Central Authority the attached │ │ application for legal aid and its annex (statement concerning │ │ the applicant's financial circumstances), for the purpose of │ │ Chapter I of the above-mentioned Convention. │ │ │ │ Remarks concerning the application and the statement, if any: │ │ │ │ │ │ Other remarks, if any: │ │ │ │ │ │ Done at ........, the ........ │ │ Signature and/or stamp │ │ │ │ │ └────────────────────────────────────────────────────────────────┘ ┌────────────────────────────────────────────────────────────────┐ │ │ │ │ │ FORM ATTACHED TO THE CONVENTION │ │ │ │ │ │ │ │ APPLICATION FOR LEGAL AID │ │ │ │ │ │ Convention on International Access to Justice, │ │ signed at The Hague, the 25th of October 1980. │ │ │ │ │ │ 1 Name and address of the applicant for legal aid │ │ │ │ 2 Court of tribunal in which the proceedings have been or will │ │ be initiated (if known) │ │ │ │ 3 a) Subject-matter(s) of proceedings; amount of the claim, if │ │ applicable │ │ b) If applicable, list of supporting documents pertinent to │ │ commenced or intended proceedings <*> │ │ c) Name and address of the opposing party <*> │ │ │ │ 4 Any date or time-limit relating to proceedings with legal │ │ consequences for the applicant, calling for speedy handling │ │ of the application <*> │ │ │ │ 5 Any other relevant information <*> │ │ │ │ 6 Done at ........, the ........ │ │ │ │ 7 Applicant's Signature │ │ │ │ │ │ <*> Delete if inappropriate. │ │ │ │ │ └────────────────────────────────────────────────────────────────┘ ┌────────────────────────────────────────────────────────────────┐ │ │ │ │ │ Annex to the application for legal aid │ │ │ │ │ │ Statement concerning the applicant's financial circumstances │ │ │ │ │ │ I Personal situation │ │ │ │ 8 name (maiden name, if applicable) │ │ │ │ 9 first name(s) │ │ │ │ 10 date and place of birth │ │ │ │ 11 nationality │ │ │ │ 12 a) habitual residence (date of commencement of the │ │ residence) │ │ │ │ b) former habitual residence (date of commencement and │ │ termination of the residence) │ │ │ │ 13 civil status (single, married, widow(er), divorced, │ │ separated) │ │ │ │ 14 name and first name(s) of the spouse │ │ │ │ 15 names, first names and dates of birth of children dependent │ │ on the applicant │ │ │ │ 16 other persons dependent on the applicant │ │ │ │ 17 supplementary information concerning the family situation │ │ │ │ │ └────────────────────────────────────────────────────────────────┘ ┌────────────────────────────────────────────────────────────────┐ │ │ │ │ │ │ │ │ │ II Financial circumstances │ │ │ │ │ │ 18 occupation │ │ │ │ 19 name and address of employer or place of exercise of │ │ occupation │ │ │ │ 20 income of the applicant of the spouse of the persons │ │ dependent on │ │ the applicant │ │ │ │ a) salary │ │ (including payments │ │ in kind) ............................... │ │ │ │ b) pensions, disability │ │ pensions, alimonies, │ │ allowances, annuities ............................... │ │ │ │ c) unemployment benefits ............................... │ │ │ │ d) income from │ │ non-salaried occupations ............................... │ │ │ │ e) income from securities │ │ and floating capital ............................... │ │ │ │ f) income from │ │ real property ............................... │ │ │ │ g) other sources │ │ of income ............................... │ │ │ │ │ └────────────────────────────────────────────────────────────────┘ ┌────────────────────────────────────────────────────────────────┐ │ │ │ │ │ │ │ │ │ 21 real property of the applicant of the spouse │ │ of the persons │ │ dependent on │ │ the applicant │ │ │ │ (please state value(s) │ │ and obligations) ............................... │ │ │ │ │ │ 22 other assets of the applicant of the spouse │ │ of the persons │ │ dependent on │ │ the applicant │ │ │ │ │ │ (securities, │ │ sharings in profits, │ │ claims, bank accounts, │ │ business capital, etc.) ............................... │ │ │ │ 23 debts and other of the applicant of the spouse │ │ financial obligations of the persons │ │ dependent on │ │ the applicant │ │ │ │ a) loans │ │ (state nature, │ │ balance to be paid │ │ and annual/monthly │ │ repayments) ............................... │ │ │ │ b) maintenance obligations │ │ (state monthly payments) ............................... │ │ │ │ c) house rent │ │ (including costs of │ │ heating, electricity, │ │ gas and water) ............................... │ │ │ │ d) other recurring │ │ obligations ............................... │ │ │ │ │ └────────────────────────────────────────────────────────────────┘ ┌────────────────────────────────────────────────────────────────┐ │ │ │ │ │ │ │ │ │ 24 income tax and social security contributions for the │ │ previous year │ │ │ │ 25 remarks of the applicant │ │ │ │ 26 if applicable, list of supporting documents │ │ │ │ 27 The undersigned, being fully aware of the penalties │ │ provided by law for the making of a false statement, │ │ declares that the above statement is complete and correct. │ │ │ │ 28 Done at ............. (place) 29 the ............. (date) │ │ │ │ 30 ........... (applicant's │ │ signature) │ │ │ │ │ │ │ │ │ │ │ │ │ └────────────────────────────────────────────────────────────────┘