S.L. 595.17 ст. 4Place of operation of the Agency. ............... ............... ............... ............... Section 4 - document) Last If in Section 5 - I confirm state of provided in contained in Name and Tick as notified with by post Data The personal the purpose of third parties required by as well as the

The Agency shall operate from such place as may be designated for this purpose by the Minister responsible for justice by notice in the Gazette. SCHEDULE

Application Form for Legal Aid Section 1 - Personal Details Name ............................................ Surname .................................................

Address .......................................................................................................... ..........................................................................................................

ID Card Number ................................ or Passport Number ........................... Tel: No. ............................................. Mobile No. ......................................... email address .................................................................................................

No. of persons in household ............................................

Next of kin: Name ................................... Surname .......................................

Address .......................................................................................................... ..........................................................................................................

Tel: No. ........................................... Mobile No. ........................................... email address ..................................................................................................

Section 2 - Reason for requesting legal aid Reason for need of being assigned a legal aid lawyer: ......................................................................................................................... ......................................................................................................................... ........................................................................................................................

Section 3 - Financial Statement

Employer ............................................. Monthly/Yearly Income € Social Security Allowance ................... Monthly/Yearly Income € Maintenance ......................................... Monthly/Yearly Income €

Other income ........................................ Monthly/Yearly Income € Bank Accounts Name of Bank ........................................................... Balance € ....................

Name of Bank ........................................................... Balance € .................... Name of Bank ........................................................... Balance € .................... Investments

Type of Investment ............................................ Balance/Value € ................. Property Address ...........................................................................................................

Address ........................................................................................................... Address ........................................................................................................... Documents to attach to application (tick where applicable and attach

Photocopy of applicant’s Identity Card salary slip (if employed) receipt of a Social Assistance, official documentary evidence

Declaration by applicant that the information supplied is truthful and gives a full picture of my affairs. I am aware that the Legal Aid Agency may verify the information this form, as well as the supporting documents, by accessing information Government filing systems, including databases, in my respect.

...................................................... ................................................ surname in block letters Signature appropriate the manner in which you wish to be communicated with or any reply: or by e-mail

Protection Statement: data contained in this form is collected by the Legal Aid Agency for processing the request for legal aid and will not be disclosed to other without the applicant’s specific consent unless this will be strictly law. The applicant has the right to request access to his/her personal data right to rectify and where applicable, erase any inaccurate, incomplete personal data processed by the Legal Aid Agency in this regard.