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protect personal information legal help help at court and family help lower equal opportunities monitoring please tick the boxes which your client would describe themselves as being ethnic monitoring mixed white asian or asian british a white and black caribbean a british a indian b irish c white other black or black british a black caribbean b black african c black other b white and black african c white and asian d mixed other b pakistani c bangladeshi d asian other other chinese prefer not to say disability monitoring the disability discrimination act defines disability as a physical or mental impairment which has a substantial and long-term adverse effect on a persons ability to carry out normal day-to-day activities if a client considers himself or herself to have a disability please select the most appropriate definition if the client has multiple disabilities please select the definition that reflects the predominant disability definitions cognitive impairment not considered disabled physical impairment sensory impairment mental health condition learning disability/difficulty long-standing illness or health condition other unknown prefer not to say 4 completion of this section is voluntary this will be treated in the strictest confidence and will be used purely for statistical monitoring and research your client s details title surname first name surname at birth if different initials date of birth sex marital status place of birth town male single divorced national insurance no female married/cohabiting civil partner job prefer not to say married but separated widowed current address town county postcode controlled work 1 page 1 version 16 november 2009

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supplier s details only complete when submitting a copy of this page with an application for extension of a cost limit please complete in block capitals name of supplier address of supplier town county postcode dx with exchange telephone number contract number financial eligibility the client is directly or indirectly in receipt of income support income-based jobseeker s allowance income-based employment and support allowance or guarantee credit yes no the client is directly or indirectly in receipt of nass payment immigration and asylum category work only yes no if the client receives income support income-based jobseeker s allowance income-based employment and support allowance guarantee credit or nass payments see above go directly to evidence section on page 3 for all other clients parts a and b must be completed does the client have a partner whose means are to be aggregated yes please complete parts a and b providing details of both client s and partner s means no please complete parts a and b providing details of client s means only part a capital client partner capital includes p equity in home above £100,000 after allowing up to £100,000 for mortgages outstanding £ £ £ £ £ £ £ £ p savings bank building society etc p investments including shares and insurance policies p valuable items eg boat caravan jewellery etc p other capital including money due to the client capital excludes p subject matter of dispute p household furniture and effects unless exceptional value p clothes tools of trade total capital client and partner £ £ £ total capital £ £ part b income p use monthly figures if paid weekly multiply by 52 divide by 12 if paid four weekly multiply by 13 divide by 12 income includes p gross monthly earnings other income p including child benefit pensions maintenance dividends tax credits benefits in kind etc £ £ £ £ £ £ £ total gross income total gross income client and partner controlled work 1 page 2

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client partner total gross income brought forward less monthly allowances p housing costs including mortgage instalment capped if client has no dependants rent capped if client has no dependants amounts should be net of housing benefit £ £ £ £ £ £ p dependants allowances partner dependants aged 15 and under aged 16 or over £ £ £ £ £ £ £ £ £ £ £ £ £ pppp tax and national insurance standard allowance for employment expenses maintenance payments actually being made eg for children and/or a former/separated spouse childcare costs because of work/self employment total allowances £ total monthly disposable income £ total monthly disposable income client and partner evidence evidence given in support of means yes no if no please record justification or exceptional circumstance controlled work 1 page 3

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data protection act access to personal data the information you provide in this form and any subsequent information we may receive will be used to process your application for legal aid it will be kept in accordance with the principles of the data protection act 1998 and any relevant confidentiality provisions if necessary we may verify or share the information you provide with other organisations such as the department for work and pensions hm revenue and customs land registry companies house and on occasion credit reference agencies we will only share the information if it is necessary to protect public funds or where we are lawfully required to do so the legal services commission may also process your information to produce management or research information the results of our research will only be published in a statistical or anonymised form the information will be kept for as long as is necessary in order for the legal services commission to fulfil its functions under the access to justice act 1999 you have the right to make a formal request in writing for access to personal data held about you to inspect it and have it corrected if it is wrong controlled work 1 page 4

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client s certification please tick the box below which applies to you:i have not already received legal help or family help lower from a solicitor or contracted supplier on this matter i have already received legal help or family help lower from a solicitor or contracted supplier on this matter if so please state when i agree to my solicitor or contracted supplier having a first charge on any money or property including costs which i recover or preserve in or in relation to the matter for which i am being advised personal injury clinical negligence and family matters only this is a true statement of all my and my partner s income and assets in the uk and abroad i understand that i must tell you immediately if there are any changes in my or my partner s financial circumstances i agree that the lsc can contact other parties to check these facts and i authorise those parties to provide the information they are asked for i understand that the lsc may check my income and capital status with her majesty s revenue and customs hmrc and authorise hmrc to carry out such checks as are necessary to verify my financial status and give that information to lsc i understand that the lsc may confirm my receipt of continuing benefit with the department of work and pensions dwp the dwp may carry out such processing as is necessary to check this information remains correct and may inform the lsc of any relevant changes i understand that if i give false information or withhold any relevant information the services provided to me may be cancelled and i may be prosecuted signed date partner s declaration if you have a partner whose details have been completed on this form then they must sign the authority below this is a true statement of all my income and assets in the uk and abroad i agree to the lsc checking these facts with other parties such as the department of work and pensions dwp and the hm revenue and customs hmrc and i authorise those parties including hmrc and dwp to provide the information they are asked for signed date note to solicitor please ensure you complete any relevant boxes on page 6 controlled work 1 page 5

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legal help and help at court tick the relevant box below if you have travelled out of the office to visit the client other than at court accepted an application from a child or patient or someone on their behalf provided legal help to a client who has already received it on the same matter within the last 6 months given telephone advice before the signature of the form claimed for outward travel before the signature of the form accepted a postal application family help lower private law are the relevant funding code criteria for family help lower met and does the case satisfy the conditions including the criteria for a significant family dispute as set out in the family specification was an application for legal representation made in this matter controlled work 1 page 6 yes no yes no

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time spent and costs item 1 attendance 2 preparation 3 help at court 4 travel and waiting total item 1 letters written 2 phone calls total profit costs £ vat £ £ number time spent value or amount of contractual or statutory charge disbursements mileage £ amount £ £ £ £ vat other disbursements £ total counsel s fees dated £ £ note when calculating profit costs the time spent on each activity and the letters and telephone calls must be separated out according to the remuneration rate which applied at the time the work was carried out part b to your unified contract specification sets the rates for contract work and specifies when franchised or non franchised rates must be charged see also part e of volume i of the lsc manual remember that you may not charge separately for letters in the totals for profit costs disbursements and counsel s fees from this form and the controlled legal representation form if applicable should be the same after adding vat and net of the amount of the statutory charge and any payment on account as those reported by you in your online submission where a staged bill has been submitted in an immigration matter a separate copy of this page should be completed for each stage reported controlled work 1 page 7 version 16 november 2009 c legal services commission

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