1
Submissions on contributions to the cost of service provision
I, (full name)
of (suburb)
submit that:
Tick one or both
Contributing to the cost of services will cause my dependent children or myself serious hardship.
The circumstances of the case mean that I should not pay the same amount of costs as other parties to the case.
Complete the relevant section To make a submission that contributing to costs will cause you serious hardship, complete:
• Part A: Serious hardship and
• Part B: Financial position .
To make a submission about the circumstances of the case that you think mean that you should not pay an equal amount of costs as other parties complete:
• Part C: Circumstances of the case .
When you have completed the form sign here
Signature Date
Send your signed and completed submission1 You need to send your signed and completed submission to:
The Registrar, Family Court (at the Court your case was heard).
2 If you have applied under Part C: Circumstances of the case , you need to provide a copy of your submission to all other applicants and respondents to these proceedings.
For respondents onlyResponse to this submission
Complete Part D: Responding to this submission if you are making a response to this submission.
Sign Part D and send the entire form* to
The Registrar, Family Court (at the Court this case was heard at)
*Do not separate your response from your copy of the completed submission form.
FAM #:
MOJ0611/07/16 Submissions on contributions to the cost of service provision 2
List each of the applicants and respondents you are sending this submission to and their address in the box below.
Name
Address
Name
Address
Name
Address
Name
Address
Name
Address
Name
Address
Name
Address
MOJ0611/07/16 Submissions on contributions to the cost of service provision 3
Part A Serious hardship1. I have financially dependant children
Yes
No
If yes state how many
2. If I am ordered to contribute to costs (tick one or more of the following)
I will not be able to meet basic living expenses. Note that limitations on you or your dependent children’s social activities and entertainment, or your inability to afford goods or services that are expensive or of a high quality or standard according to normal community standards will not be considered by the Court.
The cost of my own or my dependent children’s medical treatment for an illness or injury means that I experience significant financial difficulties. In the box below, you must state what these costs have been in the past twelve months, or will be in the future.
Because I or my dependent child has a serious illness or injury, I will experience significant financial difficulties. Serious illness or injury is one that is likely to continue for six months or more, and impacts on your ability to work or undertake normal daily activities.
Because of the cost of education for my dependent children, I will experience significant financial difficulties. In the box below, you must state what these costs have been the past twelve months.
I or my dependent children will experience serious hardship for another reason that is not described above.
Briefly explain why you ticked any of the above. You must complete this section.
Continue on a separate page if necessary.
MOJ0611/07/16 Submissions on contributions to the cost of service provision 4
3. For these proceedings I applied for:Pre-Court Family Legal Advice
Yes No Granted Yes No
Legal Aid
Yes No Granted Yes No
4. Complete Part B – Financial position
MOJ0611/07/16 Submissions on contributions to the cost of service provision 5
Part B Financial positionFor the purpose of this form a ‘partner’ is a defacto or spouse that contributes to your household income, assets and expenses.
You should note you and your partner’s income, assets and debts as they fit with your circumstances. For example:
• if you share the income from board or rent, then split the amount and record half as your partner’s income and half as your income.
• if you have a joint mortgage with your partner, record the amount you contribute to the mortgage under your debt and the amount your partner contributes under their debt.
My income in the last twelve months AmountFrequency eg. weekly
Total Yearly
My pay take home after tax (salary, wages or other personal earnings)
Income from my business after tax
My interest and other earnings on investments
Income tax credits I received
Board or rent I receive
Superannuation payments I receive
Income from pensions or benefits (including any from overseas)
Child support I receive
(A) Total per year
My partner’s income in the last twelve months AmountFrequency eg. weekly
Total Yearly
My partner’s take home pay after tax
My partner’s business income after tax
My partner’s interest/earnings on investments
Income tax credits my partner received
Board or rent my partner receives
Superannuation my partner receives
Income from pensions or benefits (including any from overseas)
Child support my partner receives
(B) Total per year
MOJ0611/07/16 Submissions on contributions to the cost of service provision 6
My assets – in New Zealand and elsewhere Value
The value of any interest I have in any land or buildings. Note that your ‘interest’ is the amount of ownership you have over the asset. E.g. the value of your house divided among all the people that share ownership of this house
Money I have in bank accounts
Cash (that is, money that is not in investments or a bank)
Value of stocks, shares, debentures or bonds I own
The value of any interest I have in plants and machinery
The value of any interest I have in motor vehicles
Money that I have lent to others, or that is in the hands of other people
Other property or assets not described above
(C) Total value of assets
My partner’s assets – in New Zealand and elsewhere Value
The value of any interest my partner has in any land or buildings
Money my partner has in bank accounts
Cash
Value of stocks, shares, debentures or bonds my partner owns
The value of any interest my partner has in plants and machinery
The value of any interest my partner has in motor vehicles
Money that my partner has lent to others, or that is in the hands of other people
Other property or assets not described above
(D) Total
MOJ0611/07/16 Submissions on contributions to the cost of service provision 7
My debts Amount RepaymentsFrequency eg. weekly
Yearly Repayments
Mortgage repayments payable by myself
Student loans repayments payable by myself
Other loans payable by myself
Payments for hire purchase for fridge, washing machine or other essential items payable by myself
(E) Total debt (F) Total yearly repayments
My partner’s debts Amount RepaymentsFrequency eg. weekly
Yearly Repayments
Mortgage repayments payable by my partnerStudent loans repayments payable by my partner
Other loans payable by my partner
Payments for hire purchase for fridge, washing machine or other essential items payable by my partner
(G) Total debt (H) Total yearly repayments
Frequent expenses include all regular costs essential to you and your family living
AmountFrequency eg. weekly
Total Yearly
Average weekly shopping bill
Rent/board
Phone/internet
Laundry and cleaning
Petrol and other vehicle running costs
Bus/train fares
Child care costs
Required crèche/nanny/babysitting
Child support payments
Medical expenses
Other maintenance paid to a former spouse or partner
(I) Total per year
MOJ0611/07/16 Submissions on contributions to the cost of service provision 8
Other expenses AmountFrequency
eg. once onlyTotal Yearly
Children’s school uniforms
School fees
Student services levy
School supplies including stationery and text books
Electricity and or gas bills
Water bills
Body corporate fees
Rates
Insurance
Essential repairs on your house
Clothing
(J) Total per year
For Courts information only
Net income of case party and partner
Total Income = A + B
Total Expenses = F+ H + I + J
Income less Expenses
Net capital of case party and partner
Total Assets = C + D
Total Debts = E + G
Assets less debts
Net income of case party only
Total Income = A
Total Expenses = F + I + J
Income less Expenses
Net capital of case party only
Total Assets = C
Total Debts = E
Assets less debts
MOJ0611/07/16 Submissions on contributions to the cost of service provision 9
Part C Circumstances of the caseI submit that it would be inappropriate to require me to pay an equal amount of the cost of lawyers and other service providers when split among parties to the case:
Because the conduct of a party to these proceedings, which had an impact on these costs
Because I have had limited involvement in these proceedings, compared to other parties.
Because these proceeding involved related domestic violence issues that should be considered. (Note the Court has to have made a finding that domestic violence has occurred.)
For another reason that is not described above.
Briefly explain why you ticked any of the above. You must complete this section
Continue on a separate page if necessary.
MOJ0611/07/16 Submissions on contributions to the cost of service provision 10
Part D Responding to this submission
I, (full name)
of (suburb)
make the following response to this submission:
Response to submission:
Signed Date