Ministry of Justice Funding Declaration Form

This form should be used to apply for fully funded Family Dispute Resolution mediation services.

The information you share is being collected by Fair Way on behalf of the Ministry of Justice (MoJ) to provide out-of-court family justice services.

See the privacy statement below for more information.

Please note: If you have had funding approved for Family Dispute Resolution or the Family Legal Advice Service in the last 12 months, you only need to complete this form if your financial situation has changed.

Any field below indicated with a * is a mandatory field and requires you fill it out.

For more information click here, or call the MoJ on 0800 2AGREE (0800 224 733).

Please provide the reference number for your case (if known)This can be found in the subject line of any emails from FDR@fairwayresolution.com

1. Applicant personal details

First name(s): *

Surname: *

Gender:

MaleFemaleGender diverse

Date of birth: *

Home address:

Email address:

Contact phone number(s):

Do you have a dependent spouse, civil union or de facto partner who has no source of income? *

YesNo

Do you have any dependent children? *

YesNo

How many?

2. Applicant eligibility details

Use this table to determine your eligibility for services:

Number of Dependents	Annual Income before tax and deductions
0: applicant only	$23,820
1: spouse/partner and/or child	$37,722
2: spouse/partner and/or children	$54,245
3: spouse/partner and/or children	$61,642
4: spouse/partner and/or children	$68,882
5: spouse/partner and/or children	$77,002
6 or more: spouse/partner and/or children	$77,002 plus $7,124 for each additional dependent

Note: A spouse or partner must have no income to be considered a dependent.

What is your estimated annual income (before tax and other deductions)? *

Please select one of the following: *

I have received a grant of civil or family legal aid within the past 12 months and my financial circumstances have not changed since the grant was approved.My estimated annual income before tax and other deductions is below the funding income threshold.My income has changed in the past 3 months, and is below the funding income threshold.

Please tell us how your income has changed in the past 3 months: *

Please attach proof of eligibility *

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E.g., a payslip or letter from your employer, bank statements for the last three months, a letter from NZ Work and Income, a copy of your most recent tax return, OR proof that you have been granted civil or family legal aid in the previous 12 months

3. Privacy statement for applicant

The information you provide in this form is being collected to assess your eligibility for funded out-of-court family justice services.

To help us determine if you are eligible for funding, or to check the information you have provided us is accurate, your information may be used by:

the Ministry of Justice (including judges and court staff)
your out-of-court family justice service provider (for example, a mediator).
the organisation that employs or engages your out-of-court family justice service provider (Fair Way).

The information you provide may also be disclosed to third parties when we believe in good faith that we are required to do so by law.

You have the right to ask for a copy of any personal information we hold about you, and to request correction of that information if you think it is wrong. To request a copy of your information, or to have it corrected, contact us at:

Address: Provider and Community Services, Ministry of Justice, SX10088, Wellington

Email: RMS.Family@justice.govt.nz

4. Applicant declaration

To proceed with your application, please read the following declaration and sign it in the box at the bottom of the section if you agree.

You can type your name or draw your signature on a mobile device by using your computer mouse.

I acknowledge that:

I must attach evidence to support the information required by this application.
The information that I have provided is true and correct.
If I provide false or misleading information, my funding may be revoked and I may be prosecuted.
If I am subsequently found to be ineligible for funding I may be required to repay the Ministry of Justice for the funded services I have received.
The assessment of my eligibility will use the information that applies to the three month period leading up to the date of this application.
My eligibility for funding may be checked by other out-of-court service providers to assess my eligibility to receive the free family justice services they may provide.

I understand that:

If circumstances change that may affect my eligibility for funding, I must immediately inform my family justice service provider who will re-administer the eligibility test using the updated information.
If this family dispute progresses to court, any application for legal aid may be compared with the information provided in this funding application for the purposes of auditing funding applications.
Any information relating to me and my family dispute that is obtained or recorded by a family justice service provider may be subject to an audit or investigation.
A copy of this form will be held by the provider for audit purposes.

I authorise the collection and use of the information I have provided in accordance with the "Privacy statement for applicant" set out in Section 3. I acknowledge that the consequences of not providing such information may result in ineligibility to receive free out of court family justice services.

Applicant's name (in full): *

Signature: *

Draw signature|Type signatureClear

Please click on the 'Type signature' option above if you do not wish to draw your signature. By signing here, you are making a legal declaration under the requirements of the Contract and Commercial Law Act 2017 that the information you have provided is true and correct.

By signing here, you are making a legal declaration under the requirements of the Contract and Commercial Law Act 2017 that the information you have provided is true and correct.

Date: *

5. Applicant checklist

Check that you have:

Completed Sections 1 & 2 above *

Given your provider: *

Proof of your income. For example, any of these items: a payslip or letter from your employer, bank statements for the last three months, a letter from NZ Work and Income, a copy of your most recent tax return OR;Proof that you have been granted civil or family legal aid in the previous 12 months

Read the Privacy Statement for Applicant in Section 3 *

Read and signed the Applicant Declaration in Section 4 *

Thank you for filling out this form. Use the Submit button below to complete your application. You will receive an email confirming you have applied for funding. It will include a record of the information you have provided in your application.

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6. Service provider confirmation

This section is for office use only.

Service provider Name:

Signature:

Date:

Supplier Name:

7. Service provider checklist

This section is for office use only.

Before you approve this application, please check you have retained a copy of the applicant's proof of eligibility for funding

9. Resolution management system

This section is for office use only.

Entered into Resolution Management System by:

Date entered into Resolution Management System: