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Form 12

Appeal Costs Fund Regulation 2010

In the matter of the Appeal Costs Fund Act 1973

and

In the matter between

(name of infant plaintiff) by (his/her) next friend

(next friend’s name)

and

(name of defendant)

APPLICATION TO THE APPEAL COSTS BOARD BY THE ABOVENAMED (name of infant plaintiff or name of the infant plaintiff’s next friend or name of the defendant) FOR A CERTIFICATE AUTHORISING PAYMENT FROM THE APPEAL COSTS FUND PURSUANT TO SECTION 24(2)

OF THE ACT

I, ______, of ______, in the State of ______, (occupation), being the abovenamed (name of infant plaintiff or name of the infant plaintiff’s next friend or name of the defendant), hereby apply to the Appeal Costs Board for a direction for payment to the defendant from the Appeal Costs Fund for the following amounts:

(Set out in numbered paragraphs each amount claimed, including dollar figures)

I certify that these costs have not been paid to the defendant by or on behalf of the infant plaintiff.

The ground on which this application is made is as follows: (delete as appropriate).

The (infant plaintiff or the infant plaintiff’s next friend) unreasonably refuses to pay the defendant’s costs in the sum of (insert dollar amount).

or

The (infant plaintiff or the infant plaintiff’s next friend) neglects to pay the defendant’s costs in the sum of (insert dollar amount).

or

The (infant plaintiff or the infant plaintiff’s next friend). is unable through lack of means to pay the defendant’s costs in the sum of (insert dollar amount).

or

The payment of the defendant’s costs in the sum of (insert dollar amount) would cause the (infant plaintiff or the infant plaintiff’s next friend) undue hardship.

All facts relevant to this application are set out in the sworn evidence of (name of person providing the sworn evidence) sworn on the ______day of ______, in the year ______.

The following documents are lodged with this application:

(List all documents lodged in support of the application)

Dated the ______day of ______, in the year ______.

(Signature of applicant)

Form 12 Version 2