IMPORTANT
THIS ENTIRE DOCUMENT MUST BE COMPLETED BY ALL CLIENTS
WISHING TO BE CONSIDERED FOR FREE LEGALLY AIDED
MEDIATION.
IT IS ESSENTIAL THAT YOU COMPLETE THIS FORM AND RETURN IT
TO US URGENTLY TOGETHER WITH PROOF OF YOUR INCOME
COVERING FROM THE LAST FOUR WEEKS TO NOW. THERE ARE
ADDITIONAL BENEFITS TO THOSE NOT RECEIVING FREE LEGAL AID IF
THEIR FORMER PARTNERS ARE ELIGIBLE, THIS WILL SAVE YOU A
CONSIDERABLE AMOUNT OF EXPENSE.
YOUR JOINT MEETING CANNOT BE ARRANGED UNTIL WE ARE IN
RECEIPT OF THE NECESSARY PROOF OF YOUR INCOME
PERSONAL & FAMILY DETAILS
Surname:
First Name(s):
Surname at birth if different:
DOB:
National Insurance Number:
Age:
Address:
Occupation:
Job Title:
Full-time/Part
Time:
Postcode:
Gross salary
per annum:
Self-Employed
/Employed:
£
Current stage of relationship
Separated, still Living together
Date of separation
Date marriage, cohabitation
or civil partnership started
Date of Decree Nisi/ Absolute/ Dissolution
Do you live with a new partner? Y/N
New partners name
Do you intend to live with
a new partner in the next
6 months? Y/N
Is it your understanding that your
former partner is living with a new
partner Y/N
1
Details of any children of the family (if more than 4 please add sheet or write overleaf)
Childs name
M/F
Date of Birth
Age
Who do they live with
Which of the following matters do you wish to discuss? Please ‘X’ box
Property
Finance
Children
All issues
Don’t Know
THIS INFORMATION WILL BE SHARED WITH YOUR FORMER PARTNER IF EITHER OF
YOU WISHES TO BE ASSESSED.
PART A & B CAPITAL
See page 12 for evidence required for each question
The Main Home
1. Do you rent? Y/N
(Includes living with parents)
If no go to next section - Shared Ownership
2. Name of Landlord
You
3.
Amount of rent paid per month
4.
Amount of housing benefit received each
month
5.
If in receipt of housing benefit, how
much do you actually pay towards your rent?
Shared Ownership
6.
Do you pay rent under a shared ownership scheme? Yes/ No
If no go to next section – Home Owner
2
Main home
7.
Amount of rent paid per
month
8.
Amount of mortgage
paid per month
9.
Name of lender
10.
Property 1
Property 2
Property 3
What is the % share
between you and the
shared ownership provider
Home Owner
11.
Do you own your own house? Yes / No
12.
What is the approx.
value of the house?
13.
Is house in joint
names? Yes/ No
14.
If yes, what is the
name of the other
joint owner?
15.
Is there a mortgage
the property? Y/N
16. Who is the mortgage
lender?
17. Whose name is on the
Mortgage?
18. Is there any other
person on the mortgage besides you or
your new partner?
If Yes, please state name
19. What is their relationship
to you?
20. Type of mortgage
Main home
Property 1
Interest only
Repayment
Other (specify)
3
Property 2
Property 3
21. Amount of mortgage
outstanding?
22. Amount of mortgage
paid per Month?
23. Amount of endowment
Insurance etc. paid p/cm
24. Does your former partner
or anyone else pay
towards the mortgage? If
Yes how much?
25. Name & relationship
to you?
26. If there are any secured loans on the property, please complete below:Name of the lender
Amount O/S
£ You pay p/m
Main home
Property 1
Property 2
Property 3
27. Do you have any interest in any other properties that are not being claimed on? Y/N
This form caters for 4 properties, if you have an interest in more than this attach separate page.
Where there are properties owned by someone other than you or by your former partner, copies of the deeds
specifying their percentages of ownership are required as evidence.
PART C INCOME DETAILS
For Proof of income see page 8
28. Are you on any of the following? If so, please ‘X’ box
Income Support
Income Based Job Seekers Allowance
Income Based Education Support Allowance
Pension Credits
Universal Credit
If you are in receipt of any of the above benefits, please do not complete any further questions in
relation to income. However, it is essential that you provide proof of these benefits (see page 8)
4
Part C Income Details continued from page 4
If you are not on any of the above benefits and you do not wish to provide any of the following
details then you cannot receive legal aid.
29. Income from Employment (Calendar Monthly)
Yourself
New Partner
Salary/ Wages (gross) Bonus/Commission (not included above)
Part time/ casual earnings/other
Dividends
30. Other income (Calendar Monthly)
Yourself New Partner
Child Benefit
Child Tax Credit
Working Families Tax Credit
Incapacity Benefit
Contribution Based Job Seekers
Allowances
Contribution Based ESA
Child Incapacity Benefit
Carers’ Allowance
Any other benefits that are not in
The above list – please list below
Yourself
31. Dividends of interest received
32. Rental income (including monies
paid by any older children still
living at home (Inc. lodgers)
33. State Pension
5
New Partner
34. Private Pension
35. Income from Trusts
36. Child Support (Inc. child care costs and costs)
CSA Letter/ bank
37. Maintenance from any prior partner including
contribution towards mortgage/ rent/ bills etc.
Any other income from any source
(please specify below)
I.e. mortgage, bills, school fees etc.
Who
38.
39.
40.
If you are self-employed please go to next section on page below.
6
Amount
SELF EMPLOYED
PLEASE SEND THIS COMPLETED FORM, TOGETHER WITH ALL THE RELEVANT
EVIDENCE, TO US BY RETURN SELF-EMPLOYED DRAWINGS
Please list all money you have spent from your self-employed or any other income for your
personal use over the last four weeks i.e. cash withdrawals, household bills, food, credit cards,
mortgage, child/spousal maintenance, petrol etc. If your bills are shared between personal and
business, please insert the figure your accountant would provide to the Inland Revenue (e.g.
50%) not the entire amount.
Please also attach your bank statement and number entries on the statement to correspond with
the list below.
Date on
Number Statement Drawings (examples above)
1
Amount
£
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
Continue overleaf or on additional sheet if necessary
We will require your most up to date accounts, tax assessment bill, bank
statements and cash book
7
Proof of Income/ Documentary Evidence Required Sheet
Section A & B Capital
You must provide evidence of the following for each property
No’s The Main Home
1-3 Tenancy Agreement
* Bank Statement for last 30 days
4
Housing Benefit letter
5
Bank statement for last 30 days
Shared Ownership
6-10 Mortgage statement
No’s Home Owner
11-25 Mortgage statement
* Bank statement for last 30 days
* Estate agents property valuation dated
* Mortgage redemption statement
26
Loan agreements
* Bank statement for last 30 days
27
Same proof as in 11-25 above including:* Bank statement for last 30 days
Section C Income
34-35 Pensions
* Letter from pension provider
confirming amount of pension paid
* Bank statement dated within last 30
days
28 State Benefits
* Bank statements dated within last 30
days and showing name/ type of benefit
------------------------------------------------* Original DWP benefit notification letter
* Latest DWP advising change in benefit
amount if amount has recently changed
* Tax Credits award notice (most recent)
* Other HMRC letter confirming amount
received (must be less than 6 months old)
* Letter from paying agency i.e. DWP, Job
Centre Plus, Pension Service
31
Dividends
Certificates/ share letter
32
Rental Income
* Rental agreement
* Bank statement for last 30 days
Rent book
Self Employed
36-37 Child Support & Maintenance
* CSA letter/ statement
* Court Order
* Bank statement for last 30 days
38-49 Other income
* Bank statements/payment receipt
books/ signed letter from source of
income
For self-employed evidence please see page 7
8
9