ONLINE APPLICATION FORM – West African Institute for Legal Aid

THE WEST AFRICAN INSTITUTE FOR LEGAL AID (WAILA)

ONLINE APPLICATION FOR CIVIL AND CRIMINAL LEGAL AID

Date of intake: _______________________________

PERSONAL INFORMATION

Mr/ Mrs/ Miss/ Ms

Surname:

First Name:

Date of Birth:

Nationality:

Identification Number:

Current Address:

________________________________________

Telephone Contact:

Email Address:

Marital Status:

Occupation/ Trade:

Name of Employer and Address:

________________________________________

MEANS

Do you receive monetary income? YES / NO

If yes, from where do you receive your income? ______________

If yes, what is your estimated monthly/yearly income? _______________

Do you have proof of this monetary income (i.e. bank account or some other monetary support? YES / NO

If you do not receive monetary income, what means do you use to sustain yourself? ______________________________________________________________________________

______________________________________________________________________________

Do you own any physical property? YES / NO

If yes, can you please provide a description of each piece of property, including address or location?

______________________________________________________________________________

DEPENDENCY

Are you married? If so, please state how many wives you have (for males) _________________

Do you have children? If so, how many? _______________________

How many individuals in total are dependent on you? ________________

Are there any additional details regarding your financial means that you would like to disclose?

______________________________________________________________________________

MERITS OF THE CASE

Please provide a description of the case

______________________________________________________________________________

Have you filed any documents with any judicial bodies or have you taken any other judicial steps towards resolving this issue? If so, can you please describe the steps you have taken?

______________________________________________________________________________

What relief are you hoping to obtain? In other words, what are you looking to gain from this case?

______________________________________________________________________________

DECLARATION OF FACTS

I____________________________________________ declare that the information I have provided to The West African Institute for Legal Aid (WAILA) is, to the best of my knowledge and belief, true. I have provided honest and accurate information and have disclosed all information which is available to me at the time of this statement. I understand that under, it is an offence to give or attempt to give false declaration and that in signing this declaration of facts I am certifying that I have not there under made any false declaration or provided any false information.

Applicant’s Signature

____________________________________

Date

__________________________________

Signature of WAILA Member taking brief (for official use only)

________________________________________

Name:

Signature:

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