Form 7.19A
(rule 7.19)

File number: 20____ ____ G __________ 

IN THE SUPREME COURT OF NEWFOUNDLAND AND LABRADOR
GENERAL DIVISION

BETWEEN:			
	(Plaintiff’s name)	PLAINTIFF	
			
AND:			
			
	(Defendant’s name)	DEFENDANT	
			
(Modify title of proceeding as necessary.)

Application for fee waiver

TO THE SUPREME COURT OF NEWFOUNDLAND AND LABRADOR OR ONE OF THE JUDGES THEREOF:

If you are a party to a proceeding in the Court, complete paragraph 1.
	
If you tick that you are in receipt of income support, please attach proof of this to this application.
	The application of (insert applicant’s name), the Applicant herein says,

1.	I am (please tick one box below)

	in receipt of income support under the Income and Employment Support Act . 

	not in receipt of income support. 

If you stated that you are not in receipt of income support, complete paragraphs 2-5.
	
Please attach documentary proof of your income (ex. notices of assessment from CRA)
	2. 	My annual income for the last three years was:

	$_______________________ (Year: ____________)

	$_______________________ (Year: ____________)

	$_______________________ (Year: ____________)

Please attach documentary proof of your monthly expenses (ex. bills)	3.	My monthly expenses are:

	(List your monthly expenses here.)

	
	4. 	The nature of my claim/defense/appeal/etc. is:

(Describe the nature of your claim, defense, appeal, etc. here, or attach a copy of the document you intend to submit if the fee waiver is granted.)
	
	5. 	Please set out any other information you think the Court should know about your ability to pay the fees required:

(Set out any other relevant information here.)

If you are a researcher seeking to have fees waived, complete paragraphs 6-7
	
	6. 	I am conducting research on: 

(Describe the nature of your research here.)
	
	7. 	I estimate that the court fees that I will incur in conducting this research amount to: 

(Provide estimate of the total amount of fees here.)

For all applications, complete paragraph 8
	
	8. 	The applicant therefore applies for an order that 

	all fees payable by (name of applicant) in proceeding (set out proceeding number) be waived; or

	(b) the following fees payable by (name of applicant) be waived:

	(List specified fees to be waived.)

If you have not attached documentary proof as required above, your application may be denied on that basis. 
 STATEMENT OF TRUTH

The contents of the within application are true to the best of my information and belief.

SWORN/AFFIRMED 
at _____________________ (city/town), ________________________ (province or, if outside of Canada, country), on the _____(day) of ____________________ (month), ______ (year), before me 			

_____________________					_____________________	
(signature)							(signature of applicant)
Commissioner, notary public, etc. 			Whose address for service is: 
(Insert address for service)
Newfoundland and Labrador

ISSUED at 					  (city/town) in the Province of Newfoundland and Labrador this 		 (day) of 			 (month), 		 (year).

(Affix seal of the court)

(signature)
Registrar/Registry clerk