Statement of Financial 		Give Details	
	Circumstances – Individual 		File Number:
	
Federal Court of Australia
Federal Circuit and Family Court of Australia	Federal Court and  Federal Circuit and Family Court Regulations 2022
Subparagraph 2.15(2)(a)		File name:
	
			Date lodged:
	
•	Cross boxes where applicable - type or print clearly providing all details required
•	Attach an extra page if you need more space for any of the details requested

Notice to applicant	

Use this form to provide information about your financial circumstances in support of an application to defer payment of court fees on the grounds that, considering those circumstances, it would be oppressive or otherwise unreasonable to require payment of the fee at the time it is required under the Regulation.

If this information is provided in relation to an existing proceeding, it will assist if you include the file number and file name (eg Smith v Commonwealth of Australia) in the appropriate fields at the top right hand corner of this page.

In considering your application the Registrar/Authorised Officer may ask you to provide additional documentary evidence to support your claim.  In that case, your application will be returned to you with instructions in the ‘Notice of request for more information’ section which appears on page 5.

	WARNING
Under the Criminal Code any person who knowingly makes an untrue representation or statement to obtain a benefit or advantage from the Commonwealth is guilty of an offence and, if found guilty, can be fined or imprisoned.

A	Details of the individual	
1.		Name		family name (surname)
     		given names
     	
						
	Address and Daytime
Telephone Number		address to which documents for you can be sent
     

     		postcode       	tel       	
						
	Occupation and
Employment		occupation
     
name of employer
     
work address
     	

B	Details of income 	

2.	The details of my and my dependants’ (if any) income (including government pensions, benefits and allowances, workers' compensation, superannuation, rent, board, interest, dividends), calculated fortnightly, are as follows [if no relevant income, write "nil" in the appropriate field below]:
[Generally, dependants are persons who rely on you or on whom you rely for financial support and included spouse, de facto partner and children]

Nature of Income	My amount	My dependents’ amount	
Fortnightly pay (after tax)	$		
Government pension, benefit or allowance (please specify)
.....................................................................................
.....................................................................................	$		
Workers’ compensation	$		
Superannuation received	$		
Interest on deposits/debentures	$		
Child support, spousal and child maintenance	$		
Other income (eg rent or board paid to you, share dividends)	$		
TOTAL	$		
Please note you may be asked to provide documentary evidence to support your claim.
3.	The full name of each of my dependants is: 

Full Name	Relationship to me	

		

4.	I receive financial support or a financial contribution from family and others, calculated fortnightly, as follows [if no financial support or contribution write "nil" below]:

Name of person providing support	Nature of support	Value in $ per fortnight	
		$	
		$	
TOTAL	$	

C	Details of property and assets 	
["Property and assets" include land, houses, money in bank accounts and other investments, cars, boats, shares, moneys owed to you, interests in a deceased estate, and interests in a trust.  If any property or asset is owned jointly with someone other than a dependant, give the name of the other owner.]
5.	My property and assets (other than bank accounts) are as follows [if no assets write "nil" below]:
	My details (my share/interest)	My dependents’ amount	
1. Liquid Assets (other than bank accounts)			
Cash (not in a bank account)	$		
Other investments (eg shares, debentures, bonds)	$		
Money owed to you	$		
Sub total  - liquid assets	$		

2. Non-liquid Assets			
House/Land			
- Market value	$			
- Amount of Mortgage	$			
- Net value	$		
Motor Vehicle			
- Market value	$			
- Amount owing on vehicle	$			
- Net value	$		
Value of household furniture and electrical goods	$		
Other assets	$		
Interest in a trust, business or partnership	$		
Sub total – non-liquid assets	$		
TOTAL of property and assets	$		

6.	Money in bank, credit union, building society accounts and other financial institutions in my name or that of my dependants’

Account Name	Name of Bank	Amount in account	
		$	
		$	
		$	
	TOTAL	$	
Please note you may be asked to provide documentary evidence to support your claim.
D	Details of expenses 	

7.	My day-to-day living expenses (including living expenses of my dependants that are normally paid by me), calculated fortnightly, are as follows:
	
Nature of Expense	$ per fortnight	Nature of Expense	$ per fortnight	
Rent/Board		Gas/electricity/other utilities		
Mortgage repayments		Telephone		
Other loan repayments		Health care		
Council/Water rates		Child care		
Insurance premiums		Education		
Food		Other:		
Clothing		Other:		
Spouse/Child maintenance		Other:		
Travel and motor vehicle		Other:		
Total of Column 1	$	Total of Column 2	$	
Total of Column 1 and Column 2	$	
Please note you may be asked to provide documentary evidence to support your claim.

E	Details of liabilities 	

["Liabilities" include outstanding mortgages, credit card debts, other moneys owed by you.  If any liabilities are owed jointly with someone other than a dependant, give the name of the other person.]
 [if no liabilities write "nil" below]

8.	My liabilities are as follows:

	My details	My dependants’ details	
Amount owing on my mortgage	$	$	
Amount owing on other loans	$	$	
Credit card			
- Amount owing	$	$	
- Limit of the card	$	$	
Amount owing to any businesses or individuals (please include details of each liability)	$	$	
Other, please specify
			
TOTAL amount owing	$	$	
Please note you may be asked to provide documentary evidence to support your claim.
F	Additional information	
[Please set out any other information concerning your financial position which you believe will help the Registrar or Authorised Officer decide your application for exemption of court fees.]	
     	
     	
     	
     	
     	
     	
     	
     	
     	
     	
     	
     	
     	
     	
     	
     	
     	
     	
     	
     	
     	
     	
     	
     	
     	
     	
     	
     	
     	
     	

G	Affidavit of applicant (to be signed in the presence of the witness)	
I swear/affirm (cross out incorrect one) that:
1.	I am providing this information in support of an application in relation to court fees.
2.	I have read this statement and the details and other information attached to it.
3.	The facts in it that are within my personal knowledge are true.
4.	All other facts are true to the best of my knowledge, information and belief.
5.	I have disclosed all relevant financial information.
6.	I am aware that it is an offence to provide information or a document in connection with this application that is false or misleading.
7.	I will notify the Court Registry if there are any changes to my circumstances that alter the information given in this statement while the Court is dealing with my case.	

Signature	Sworn/affirmed [Cross out incorrect one]
	Place:     	Date:      /     /               	

Before me (signature of witness)	Full name of witness (please print)
	     	

Justice of the Peace	Other authorised person    	specify      

This application was prepared by:		applicant	lawyer  

(print name if lawyer)	     	

Court Use Only
Notice of request for more information	
Having considered your application, the Registrar/Authorised Officer requests you to provide documentary evidence and/or additional information about  your income, assets, liabilities and day-to-day living expenses to support your claim
In particular, you will need to provide the following:	
     	
     	
     	
     	
     	
     	
     	
     	
     	
     	
     	
     	
     	
     	
     	
     	
     	

The documents listed above should be provided within 14 days of the date on which this notice was issued.  You can provide the originals or photocopies to the Court attached to the back of this application.

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Signature of officer	date issued
	
Authorised by General Counsel, Deputy Principal Registrar FCA/Principal Registrar FCFCOA 01/04/2023