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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