PROCEDURE GUIDE FOR MAGISTRATE COURT APPEALS

1. Appellant
1.1 To commence an Appeal against a decision of a Magistrate the Appellant needs to
lodge at the District Court Registry 3 copies of the appeal notice (Attachment
1). The person who commences the appeal is referred to as the Appellant!.
The other party is referred to as the Respondent!.
1." The Appellant will need to pay the prescri#ed fee for the filing the $otice of
Appeal% which is &3'(.)) for an indi*idual or &+"1.)) for a corporation. The
filing fee is automatically wai*ed for,
(a) the holder of a health care card% a health #enefit card% a pensioner
concession card or a Commonwealth seniors card-
(#) the holder of any other card issued #y the Department of .ocial .ecurity
or the Department of /eteran0s Affairs of the Commonwealth that certifies
entitlement to Commonwealth health concessions-
(c) a prisoner or person lawfully detained in a pu#lic institution-
(d) a person under 11 years of age-
(e) a person in recept of a youth training allowance% or an austudy allowance%
as defined in section "3(1) of the Social Security Act 1991 (C0th)-
(f) a person in receipt of #enefits under the Commonwealth student
assistance scheme 2nown as A3..T4D5 .cheme-
(g) a person granted legal aid in respect of the proceedings in relation to
which the fee would otherwise #e paya#le.
6or other people% there is a discretionary power to wai*e the filing fee. To
apply a party needs to file an 7Application to Remit 6ees 8 6orm "0 (6orm "!).
A copy of this form is at Attachment 1.
To apply for the hearing fee to #e wai*ed a completed and signed 6orm " must
#e lodged with the District Court Registry.
1.3 The Court will insert into the appeal notice the date and time for an initial hearing%
called a 7Directions 9earing0. This hearing is #efore a Registrar.
1.: The Court will 2eep 1 copy of the $otice of Appeal and return " stamped (sealed)
copies to the Appellant. The Directions 9earing will #e a#out ( wee2s after
the date on which the appeal is commenced. This time inter*al is to allow the
Appellant time to ser*e the appeal papers on the Respondent and for the
Respondent to ta2e legal ad*ice in relation to the Appeal. ;t also allows time
for the Court to o#tain the file from the <urisdiction in which the original
decision was made.
1.: =hen the Appellant ser*es the appeal notice on the Respondent% the Appellant
must attach to it a notice of respondent0s intention (Attachment 3), "))' DCR
r'1(().
1.' The District Court rules pro*ide that the appeal notice is to #e personally
ser*ed on the Respondent, "))' DCR r'1(:).
1.( ;f the Respondent is in a prison% the appeal notice may #e ser*ed #y sending it
to the superintendent of the prison #y ordinary pre8paid post.
1.> Appellants may find it con*enient or indeed necessary to use a professional
process ser*er to ser*e the appeal notice.
1.1 ;f an Appellant cannot find an address for the Respondent% the Appellant can
apply to the Court for an order allowing ser*ice in some other way% for
e?ample% #y ad*ertisement or #y post on a third party. The process to o#tain
orders of this type is set out in the @rocedure Auide (see section :).
1.+ As soon as practica#le after ser*ing the Respondent the Appellant must file a
ser*ice certificate (Attachment "). This can #e posted to the Court at,
District Court of =estern Australia
')) 9ay .treet
@BRT9 =A ()))
;t may also #e fa?ed to the Court on +:"' ""(1.
2. Respondent
".1 The appeal notice will specify when the directions hearing has #een listed for
in the appeal. A Respondent should ma2e e*ery effort to attend this directions
hearing as a failure to attend may result in orders #eing made in relation to the
appeal in their a#sence.
"." A Respondent who does not wish to contest the appeal may tic2 the
appropriate #o? in the notice of respondent0s intention ser*ed with the appeal
notice identifying that he or she does not wish to contest the appeal. The
notice should then #e signed% filed and ser*ed.
".3 A Respondent who wishes to contest the must complete the appropriate
sections of the notice of respondent0s intention ser*ed with the appeal notice.
The notice should then #e signed% filed and ser*ed.
".: The notice must #e filed with the court either #y personally attending the
Registry or #y sending or fa?ing as set out in par 1.+.
".' The notice must also #e ser*ed on the appellant% which can #e done #y posting
or fa?ing it to the address for ser*ice in the appeal notice.
3. Initial Diretions !earin"
3.1 At the directions hearing% the Registrar will re*iew the appeal to chec2
whether it is ready to proceed to final hearing. This will include chec2ing the
material which has #een sent to the Court #y the Magistrates0 Court. The
Registrar will ma2e any orders that are necessary to get the appeal in order for
the formal hearing. ;f reCuired% a further directions hearing will #e listed.
"
3." ;f the appeal is ready to #e listed for a final hearing% the Registrar will set a date
and time for the final hearing.
3.3 ;f the appeal cannot #e listed at the Mention% the Registrar ma2e any orders
reCuired and list the Appeal for a further directions hearing.
#. General $atters applia%le to all parties
:.1 ;f a party reCuires the Court to ma2e an order #efore the hearing of the appeal the
party will need to file and ser*e cham#er summons. 6or e?ample this would
#e used where,
(a) the Appellant cannot locate the Respondent and reCuires the Court to
ma2e an order for su#stituted ser*ice- or
(#) the Appellant needs lea*e to appeal out of time- or
(c) a party wishes to ha*e the Court rely on additional e*idence from that
relied on #y the Magistrate.
:." A cham#er summons is the form of Attachment :. The party ma2ing the
application will also need to file and ser*e an affida*it (Attachment 1) setting
out the facts which the party ma2ing the application would li2e to #ring to the
Court0s attention to support its application for the orders sought.
:.3 The party ma2ing the application will need to file 3 copies of each document
with the Court. The Court will write in the hearing date and time% 2eep one
copy and return the other " to the party.
:.: The Court will generally list the cham#er summons for hearing at the
directions hearing in the Appeal.
:.' The party ma2ing the application will need to ser*e a copy of the cham#er
summons (with the Court hearing date inserted)% together with the affida*it in
support of the application% on the other parties e?cept in the case of an
application for su#stituted ser*ice.
&. !earin" o' t(e appeal
'.1 ;f a party wishes to file any written su#missions for the Dudge to consider prior to
the hearing% the su#missions should #e filed and ser*ed at least > clear
wor2ing days prior to the date of the hearing, "))' DCR r (1.
'." The parties should attend the District Court at least 1' minutes prior to the
scheduled starting time for the appeal. 6or appeals held in @erth in the District
Court 3uilding% the Courtroom num#er will #e displayed on the screens on the
right hand side of the foyer as you enter the #uilding.
'.3 4pon entering the Courtroom% if the Court is already in session% the protocol is to
ma2e a short #ow towards the Dudge.
3
'.: ;f the Court is not in session% the party should approach the staff mem#er sitting in
front of the Dudge0s #ench. This person is 2nown as the 7Associate0. The
party should identify themsel*es to the Associate.
'.' =hen the Dudge enters the Court and the Associate announces the case% the
protocol is to stand and ma2e a short #ow to the Dudge. This protocol also
applies when the Court is ad<ourning.
'.' The Dudge should #e addressed as 5our 9onour!.
'.( Typically% the Appellant will #e as2ed to address the Court first and then the
Respondent.
'.> The hearing #efore the Dudge is a reconsideration of the e*idence #efore the
Magistrate. A party is not allowed to adduce e*idence that was not #efore the
Magistrates Court unless the party has o#tained the lea*e of the Court. The
Court is not to grant lea*e unless there are e?ceptional circumstances,
Magistrates Court (Civil Proceedings) Act 2004 (=A)% s:)(').
'.1 The Dudge will either determine the appeal at the hearing and gi*e reasons
there and then% or ad<ourn and pro*ide written reasons for the decision. ;f this
occurs% a further hearing will #e listed for the Dudge to hand down the
decision. The parties will #e notified when the decision has #een written and
the further hearing listed. Typically% the Dudge will ta2e #etween 1 and 3
months to consider the appeal and pro*ide written reasons.
). F*rt(er En+*iries
(.1 6or any further enCuiries please contact the Court on +:"' "3::.
,. For$s
Atta($ent -lan. pro 'or$a /or.ed e0a$ple
1 Appeal notice Appeal notice 8 RE e?ample
" .er*ice certificate .er*ice certificate 8 RE e?ample
3 $otice of respondent0s
intention
$otice of respondent0s intention 8
RE e?ample
: Application in an appeal Application in an appeal F RE
e?ample
' Consent notice Consent notice 8 RE e?ample
( Discontinuance notice Discontinuance notice 8 RE
e?ample
> Affida*it Affida*it F RE e?ample
1 6orm " 6ee =ai*er
:
District Court Rules 2005 1/A2 For$ ) Appeal 3otie 1r. &1 1l22
District Court of =estern Australia Appeal $o,
Appeal 3otie
@arties Appellant
Respondent
Pri$ar4 o*rt5s deision
@rimary court
Case um#er
@arties
Date of decision
Dudicial officer
Decision details
i
Appeal details
$otice of appeal The appellant appeals to the District Court against the a#o*e
decision
Arounds of appeal
ii
1.
Acts that allows
appeal
iii
.ection,
$otice to the
respondent
i*
;f you want to ta2e part in this appeal you must file a 6orm 1
(attached) under the District Court Rules 2005 within "1 days after
the date on which you are ser*ed with this notice and ser*e it on the
appellant.
;f you file a 6orm 1 you must attend a directions hearing at the time
and place stated #elow.
Gast date for
appealing
Gast date,
;s an e?tension of time needed. 5esH$o
Directions
hearing
*
Date, Time,
@lace,
Appellant5s details 'or ser6ie
6i
$ame
.treet Address
Telephone
Bmail Address
Reference $o.
6a? $o,
.ignature of
appellant or
lawyer AppellantH Appellant0s lawyer
Date,
3ote to For$ ) 8
'
i
B?amples,
Dudgment against defendant for &:)%)))
Dismissal of claim to reco*er possession of real property.
ii
.et out the grounds in num#ered paragraphs.
iii
.tate the short title of the Act under which the appeal is #eing made.
i*
A copy of 6orm 1 ($otice of respondent0s intention) must #e attached to this form when it is ser*ed on the
respondent.
*
The court will complete this row when the appeal notice is filed.
*i
;f the appellant is represented #y a lawyer% the appellant0s details #elow must #e the lawyer0s. ;f the appellant
is self8represented% the details must #e the appellant0s personal details.
District Court Rules 2005 1/A2 For$ ) Appeal 3otie 1r. &1 1l22
Restrainin" orders e0a$ple
District Court of =estern AustraliaAppeal $o,Appeal 3otie @artiesRodne4 S$it(
Appellant

Anna%el 7ones Respondent Pri$ar4 o*rt5s deision
@rimary court
Case num#er
@arties
Date of decision
Dudicial officer Magistrates Court 8 Doondalup
MCD "3:H ")1)
Anna#el Dones (Applicant)
Rodney .mith (Respondent)
1 6e#ruary ")11
Magistrate 3lac2
Decision details Misond*t restrainin" order $ade a"ainst respondent
1. Appeal details$otice of appeal The appellant appeals to the District Court against the a#o*e
decisionArounds of appealThe Magistrate did not allow the appellant to cross e?amine the
respondent a#out pre*ious relationships in which she #ecame o#sessi*e and demanding.
". The Magistrate did not allow Bric 9ill to gi*e e*idence a#out the respondent0s #eha*iour
towards her once their relationship ended% in particular a#out the lies she told a#out him.
3. The Magistrate did not agree to the appellant0s reCuest to ad<ourn the hearing so that the
appellant could produce emails to the Court which would show that the respondent was
lying in the e*idence she ga*e to the Magistrate.
:. 9ad the Magistrate heard this e*idence% it would ha*e #een *ery o#*ious that the respondent
was lying a#out the appellant0s #eha*iour and that no misconduct restraining order was
<ustified.
Acts that allows appealRestraining rders Act 199! (=A) section, (:
$otice to the respondent ;f you want to ta2e part in this appeal you must file a 6orm 1 (attached)
under the District Court Rules 2005 within "1 days after the date on which you are ser*ed with this
notice and ser*e it on the appellant.

;f you file a 6orm 1 you must attend a directions hearing at the time and place stated #elow. Gast
date for appealingGast date, "" 6e#ruary ")11
;s an e?tension of time needed. $oDirections
hearingDate, Time,
@lace,
Appellant5s details 'or ser6ie$ame
.treet Address
Telephone
Bmail Address
Reference $o.Rodney .mith
1"3 Roc2hamptom Dri*e% .afety 3ay% =A% (1(+
+:"( ">+3 6a? $o, nHa
rodney.smithIiientcom.au.ignature of appellant or
lawyer
AppellantH Appellant0s lawyerDate, ") 6e#ruary ")11
District Court Rules 2005 1/A2 For$ , Ser6ie erti'iate 1r. &11,22
Ma"istrates Co*rt "eneral lai$ e0a$ple
District Court of =estern AustraliaAppeal $o, Ser6ie erti'iate @arties Appellant
Respondent Certificate; certify that on JdateK at J"laceK Jna#e o$ serverK ser*ed the respondent
personally with these documentsL
A copy of an appeal notice dated JdateK-
A copy of e*ery other document that was filed with the appeal notice-
A copy of 6orm 1 ($otice of respondent0s intention).
; underta2e to file an affida*it of ser*ice if the Court reCuires me to.
.ignature of appellant or lawyer
Appellant H Appellant0s lawyerDate,
3ote to For$ , 8
1. ;f the documents were posted to the: superintendent of the prison in which the respondent is imprisoned%
modify this certificate to say when they were posted and to what prison.
District Court Rules 2005 1/A2 For$ , Ser6ie erti'iate 1r. &11,22
Ma"istrates Co*rt Restrainin" orders e0a$ple
District Court of =estern AustraliaAppeal $o, "3: of ")11 Ser6ie erti'iate @arties Rodne4
S$it( Appellant

Anna%el 7ones Respondent
Certificate; certify that on ": 6e#ruary ")11 at Roc2ingham 3illy Blliot ser*ed the respondent
personally with these documentsL
A copy of an appeal notice dated ") 6e#ruary ")11-
A copy of e*ery other document that was filed with the appeal notice-
A copy of 6orm 1 ($otice of respondent0s intention).
; underta2e to file an affida*it of ser*ice if the Court reCuires me to.
.ignature of appellant or lawyer
Appellant H Appellant0s lawyerDate,
District Court Rules 2005 1/A2 For$ 8 3otie o' Respondent5s intention 1r.&32
Ma"istrates Co*rt "eneral lai$ e0a$ple
District Court of =estern Australia Appeal $o, 3otie o' respondent5s intention @arties Appellant
Respondent $otice
JTic2 one #o?KThe respondent intends to ta2e part in this appeal.
The respondent does not intend to ta2e part in this appeal and will accept any order made #y
the court in the appeal other than as to costs. Arounds for upholdingThe respondent will argue
the primary court0s decision should #e upheld on the grounds relied on #y the primary court in
its decision. Ether grounds for upholdingThe respondent will argue the primary court0s decision
should #e upheld on the following grounds not relied on #y the primary court in its decision F
1./ariation
3
The respondent applies for the primary court0s decision to #e *aried as followsL

The respondent will argue the primary court0s
decision should #e *aried on the following grounds F
1. Cross8appeal
3
The respondent also appeals against the primary court0s decision and will
rely on the following grounds F
1. Gast date for appealing Gast date,
;s an e?tension of time neededM 5esH$o Respondent5s details 'or ser6ie $ame
.treet Address
Telephone
Bmail address
Reference $o.
6a? $o,.ignature of respondent or lawyer
Respondent H Respondent0s lawyerDate,
$otes to 6orm 1
1. ;f this #o? is tic2ed% complete one or more of the ne?t ' rows and the respondent0s details for ser*ice.
". ;f this #o? is tic2ed% ignore the ne?t ' rows and complete the respondent0s details for ser*ice.
3. .et out the grounds in num#ered paragraphs.
:. Complete this only if the respondent also appeals against the primary court0s decision.
'. ;f the respondent is represented #y a lawyer% the respondent0s details #elow must #e the lawyer0s. ;f the
respondent is self represented% the details must #e the respondent0s personal details.
District Court Rules 2005 1/A2 For$ 8 3otie o' Respondent5s intention 1r.&32
Ma"istrates Co*rt restrainin" orders e0a$ple
District Court of =estern Australia Appeal $o, "3: of ")11
3otie o' respondent5s intention
@arties Rodne4 S$it( Appellant
Anna%el 7ones Respondent $otice
JTic2 one #o?K The respondent intends to ta2e part in this appeal.
The respondent does not intend to ta2e part in this appeal and will accept any order made #y the
court in the appeal other than as to costs. Arounds for upholding The respondent will argue
the primary court0s decision should #e upheld on the grounds relied on #y the primary court in
its decision. Ether grounds for upholding The respondent will argue the primary court0s
decision should #e upheld on the following grounds not relied on #y the primary court in its
decision F
1. The fact that the appellant has commenced this appeal is further e*idence of the *icious
and unrelenting campaign of intimidation and harassment he has engaged in towards me.
/ariationThe respondent applies for the primary court0s decision to #e *aried as followsL

The respondent will argue the primary court0s
decision should #e *aried on the following grounds F
1. Cross8appeal
3
The respondent also appeals against the primary court0s decision and will
rely on the following grounds F
1. Gast date for appealing Gast date,
;s an e?tension of time neededM $o Respondent5s details 'or ser6ie $ame
.treet Address
Telephone
Bmail address
Reference $o. Anna#el Dones
4nit '% :: Monash A*enue% $edlands% =A "))+
+:"' """" 6a? $o, nHa
nHa.ignature of respondent or lawyerAnnabel Jones
Respondent Date, 1 March ")11
District Court Rules 2005 1/A2 For$ 9 Appliation in an appeal 1r &8A2
District Court of =estern AustraliaAppeal $o,Appliation in an appeal@artiesAppellant
Respondent Applicant ApplicationThe applicant applies for F
Conference #etween parties
JTic2 one #o?KThe parties to this application ha*e conferred a#out the issues gi*ing rise to
this application and ha*e not resol*ed them.
The parties to this application ha*e not conferred a#out the issues gi*ing rise to this
application #ecause F
.ignature of applicant or
lawyer
ApplicantH Applicant0s lawyerDate,
$otes to 6orm + 8
1. .tate F
the order or orders sought- and
the written law and pro*ision under which the application is made.
". .tate the reasons why the parties ha*e not conferred.
District Court Rules 2005 1/A2 For$ 9 Appliation in an appeal 1r &8A2
Ma"istrates Co*rt Restrainin" orders e0a$ple
District Court of =estern AustraliaAppeal $o, "3: of ")11
Appliation in an appeal
@artiesRodne4 S$it( Appellant

Anna%el 7ones Respondent
Applicant Anna#el Dones (Respondent) ApplicationThe applicant applies for F
1. An order that this application #e heard #y telephone.
". An order that the respondent ha*e lea*e to participate in the hearing of the appeal #y *ideo lin2
to a secure location.
This application is made pursuant to Magistrates Court (Civil Proceedings) Act 2004 (=A) s :)(:)
(#).
Conference #etween parties
JTic2 one #o?KThe parties to this application ha*e conferred a#out the issues gi*ing rise to
this application and ha*e not resol*ed them.
The parties to this application ha*e not conferred a#out the issues gi*ing rise to this application
#ecause any form of communication #etween the parties has% in the past% inflamed the issues
#etween them and ne*er #een the su#<ect of a fruitful con*ersation.
.ignature of applicant or
lawyerAnnabel Jones
Respondent Date, 1 March ")11
District Court Rules 2005 1/A2 For$ 1: Consent 3otie 1r. &8 -2
District Court of =estern Australia Appeal $o,Consent notie @arties Appellant
Respondent Consent=e consent to the following orders #eing made F
.ignature of appellant or lawyer
Appellant H Appellant0s lawyerDate,.ignature of respondent or lawyer
Respondent H Respondent0s lawyerDate,
District Court Rules 2005 1/A2 For$ 1: Consent 3otie 1r. &8 -2
Ma"istrates Co*rt Restrainin" orders e0a$ple
District Court of =estern Australia Appeal $o, "3: of ")11 Consent notie
@arties
Rodne4 S$it( Appellant
Anna%el 7ones Respondent
Consent=e consent to the following orders #eing made F
1. The directions hearing listed for 3 March ")11 at 1).3)am #e ad<ourned to a date not earlier
than 3 April ")11.
". The appellant ha*e lea*e to file and ser*e a su#stituted appeal notice in terms of the minute
dated 3 March ")11 filed with this consent notice.
.ignature of appellant or lawyer
Appellant Date,.ignature of respondent or lawyer
Respondent Date,
District Court Rules 2005 1/A2 For$ 11 Disontin*ane 3otie 1r.&82
District Court of =estern Australia Appeal $o,
Disontin*ane notie
@arties Appellant
Respondent
$oticeThe appellant discontinues this appeal.
.ignature of appellant or lawyer
Appellant H Appellant0s lawyerDate,
District Court Rules 2005 1/A2 For$ 11 Disontin*ane 3otie 1r.&82
Ma"istrates Co*rt restrainin" orders e0a$ple
District Court of =estern Australia Appeal $o, "3: of ")11
Disontin*ane notie
@arties Rodne4 S$it( Appellant

Anna%el 7ones Respondent
$oticeThe appellant discontinues this appeal.
.ignature of appellant or lawyer
Appellant H Appellant0s lawyerDate,
1" March ")11
District Court Rules 2005 1/A2 For$ 1A. A''ida6it 1r.23A2
1. District Court of =estern AustraliaAppeal $o,A''ida6it@arties@erson ma2ing affida*itDate
made@urpose6iled #yJPartyK;nde?Contents@ageA$$idavit o$ %incent van &og'
". Attac'#ent %%& 1(M) Citi*en+s ,irt' certi$icate
Attac'#ent %%& 2(-etter $ro# ) S#it' to . )ones dated / Marc' 1999 1
>
1
@age 1
1% Jna#e0 address and occu"ation o$ "erson #a1ing t'e a$$idavitK% Jinsert 2ords o$ oat' or
a$$ir#ation in accordance 2it' t'e Eaths% Affida*its and .tatutory Declarations Act "))'K as
follows F
1. Jinsert content o$ a$$idavit in nu#,ered "aragra"'sK.
".
This affida*it is Js2orn3 a$$ir#edK #y Jna#e o$ "erson #a1ing t'e a$$idavitK in the presence of an
authorised witness at J"laceK on JdateK.
JSignature o$ "erson #a1ing t'e a$$idavit.K
JSignature o$ aut'orised 2itnessK
Authorised witness
J4a#e o$ aut'orised 2itnessK
J5uali$ication o$ aut'orised 2itnessK
1. The affida*it must comply with R.C Erder 3>.
". B?ample, To support summons #y plaintiff dated 1 May ")1) for summary <udgment.
3. The inde? must comply with R.C Erder 3> rule "(>). 6orm 1Acontains in italics an e?ample of an inde?.
:. @age 1 must #e on a separate sheet of paper from the a#o*e.
'. The at's0 A$$idavits and Statutory Declarations Act 2005 @art 3 sets out the reCuirements for affida*it and
who are authorised witnesses for affida*its.
District Court Rules 2005 1/A2 For$ 1A. A''ida6it 1r.23A2
Ma"istrates Co*rt Restrainin" orders e0a$ple
District Court of =estern AustraliaAppeal $o, "3: of ")11
A''ida6it
@artiesRodne4 S$it( Appellant

Anna%el 7ones Respondent
@erson ma2ing affida*itAnna#el Dones Date made3 March ")11@urposeTo s*pport appliation
dated 3 Mar( 2:11 'or lea6e to (a6e t(e appeal (eard %4 6ideo lin..
1. 6iled #yRespondent ;nde?Contents@ageAffida*it of Anna#el Dones
". Attachment AD1! 8 Bmail Rodney .mith to Anna#el Dones% 1" 6e#ruary ")11
3. Attachment AD"! 8 Bmail Rodney .mith to Anna#el Dones% 13 6e#ruary ")11
1
3
:
DISTRICT COURT 1FEES REGULATIO3S2 2::2
FORM 2
APPLICATIO3 TO REMIT FEESIn t(e Distrit Co*rt o' /estern A*stralia
3o. ; Plainti''< .....................................................NNNNNNNNNNNN....
N.......................De'endant<.........................NNNNNNNNNNNNNN.....................
N...............N......Appliant<...............................=============.....................
=............................Address<...............................=============.....................
=............................
...............................=============.....................=..........................===..=
...............................=============.....................=..........................===..
=NNHNN..HNN. NNNNNNNN.
Date of 3irth MDG $o.The following reasons are the special
reasons for applying to ha*e the fees in relation to the a#o*e matter wai*edH reducedH refundedH
deferredO.
..................................................................................................NNNNNNNNNNN.............
...................................................................................................................NNNNNNNNNN
...................................................................................................................NNNNNNNNNN
...................................................................................................................NNNNNNNNNN
...................................................................................................................NNNNNNNNNN
6 Stri1e out t'ose t'at are not a""lica,le7;f the special reason include that an important right
or o#ligation affecting the community or a significant part of the community will #e determined%
what is the right or o#ligationM J&ive details o$ eac' rig't or o,ligation0 and e8"lain 2'y it e$$ects t'e co##unity or a
signi$icant "art o$ t'e co##unity79
..................................................................................................NNNNNNNNNNN.............
...................................................................................................................NNNNNNNNNN
...................................................................................................................NNNNNNNNNN
...................................................................................................................NNNNNNNNNN
;f the special reasons include the de*elopment of the law generally will #e effected so as to
reduce the need for further litigation% what law will #e de*eloped generallyM J&ive details o$ 'o2 a
deter#ination to t'at la2 2ill reduce t'e need $or $urt'er litigation79
..................................................................................................NNNNNNNNNNN.............
...................................................................................................................NNNNNNNNNN
...................................................................................................................NNNNNNNNNN
...................................................................................................................NNNNNNNNNN
;f the special reasons include financial hardship the information reCuired in the following part of
this form must #e pro*ided #y the applicant if the applicant is a natural person.; am employed as
a ................................ #y ....................................... . O Their #usiness address
is ...................................................................... .O; am unemployedH a pensionerO and registered
with the Department of .ocial .ecurity at ..................................................................................... .;
am singleH marriedH separated.O; ha*eH do not ha*eO a dependant wifeH hus#andHde facto partnerO
and .............. dependant children.My wee2lyH fortnightlyO income and e?penditure is as follows
(in whole dollars) 8Ino$e
E0pendit*re/a"e;salar4;%ene'it 1net2 RentH#oard
&.elf & Mortgage payment &.pouse
& Maintenance for dependants &De facto partner &
6ood &Total &
BlectricityHgas &Mone4 in %an. or ot(er 'inanial instit*tion Telephone
&.elf & =ater &.pouse
& Rates and ta?es &De facto partner &
Court orders &Total & Gease or other
(gi*e details) &
NNNNNNNNNNNNNNNNNNNN.. NNNNNNNNNNNNNNNNN
NNNNNNNNNNNNNNNNNNNN. NNNNNNNNNNNNNNNNN
;ncome from in*estments & Ether de#ts owing (gi*e details) &
NNNNNNNNNNNNNNNNNNNN.. NNNNNNNNNNNNNNNNN
NNNNNNNNNNNNNNNNNNNN. NNNNNNNNNNNNNNNNN
Ether income &Money owed to me &TOTAL >
TOTAL >ASSETS
?ALUE My assets and lia#ilities are as follows 8 9ouse or other real property (gi*e
addresses).................................................................NNNNNNNNN............... &
...........NNNNNNNNNNNNNNNNNNNNNN................. &TOTAL
>Motor 6e(iles 1ar@ *tilit4@ $otor 4le@ tr*.@ et.2Ma.e and $odel
Re". 3o.NNNNNNNNNNNNNNNNN.. NNNNN. &
NNNNNNNNNNNNNNNNN.. NNNNN. &TOTAL
>9ome contents Tele*ision
yes H no & /ideo recorder yes H no &.tereo system yes H no
& 6urniture yes H no &Dishwasher yes H no &
Microwa*e o*en yes H no &Collection of coins% stamps% etc. &Ether collecta#les
&;nterest in #usiness or company &Ether assets &TOTAL
>
LIA-ILITIESMortgage to ..........................................NNNNNNNNNN...... for
&Ether to ....................................................NNNNNNNNNN.. for &Time to pay
order .....................................NNNNNNNNNN. for &TOTAL
>;f the special reasons include financial hardship the information reCuired in the following part of
this form must #e pro*ided #y the applicant if the applicant is a corporation or incorporated
association.;$CEMB&G;A3;G;T;B.&A..BT. (/AG4B)&Si"nat*re o' appliant<
Date< ; ;6 Stri1e out 2ords t'at are not a""lica,le7
4ote: ;t is an o$$ence under regulation !(4) o$ t'e District Court (<ees) Regulations 2002 $or a "erson to #a1e a
state#ent or re"resentation in t'is a""lication t'at t'e "erson 1no2s or 'as reason to ,elieve is $alse or #isleading
in a #aterial "articular7 .'e #a8i#u# $ine is =1 0007