The Secretary /Authority/ Committee. Sir, widow of wife at present residing at beg to apply for legal aid/advice under the following circumstances. Namely : 1. I am employed not employed (a) Nature of employment/ occupation/ trade/ business. (b) Whether employed in the Army Navy Air force Police Force retired therefrom. (c ) Since what time /- Rs. 2. My monthly Income is 3. (a) My residential premises are rented in my Name or jointly or they are owned by me Alone or jointly. /- (b) The rent thereof or the value thereof Rs. I have agricultural lands at bearing Survey No. 4. /- paying assessment of Rs per annum. (State, if owned taken on rent) Government of Orissa Law Department Form of Application for Legal Aid or Advice FORM - A {SEE REGULATION 17(1)} TO I aged about son daughter Rs. /- (a) Income thereof is /- Rs. (b) Value of produce thereof is My other sources of Income are ( give particulars) 5. My other assets/properties/effects and their value 6. Published on National Portal of India (india.gov.in) Yes No Yes No I have have not disposed of any of my properties/ assets and effects within a period of six Published on National Portal of India (india.gov.in) I am willing to furnish such further informations may be required for the purpose of enabling you to 14. consider this application fully. I am am not in a position to pay court costs and cost of miscellaneous proceedings. (The 15. applicant may also state the amount which he is prepared to pay by way of costs and miscellaneous /- Rs. costs or a proportion or part thereof). I shall reimburse the State Government all cost, charges and expenses incurred by the Committee in 16. giving me legal aid, if the Court passes a decree or order in my favour awarding costs to me or their monetary benefits or advantage or if I cease to be entitled to legal aid under these regulations. 17. The above statements are true to the best of my knowledge and belief. Date : Place: Signature of Applicant. 7. months prior to the date of this application by way of sale, gift, mortgage or otherwise. The number of members of my family is and their relationship with me is as 8. under:- The number of dependant members in my family is and their relationship with 9. me is as under: - 10. The income, if any, of other members of my family residing with me is as under :- 11. The nature of legal aid or advice required is in respect of :- (State the nature of dispute, claim of right and state the documents in support thereof,State also separately the origin of dispute, claim or rights of other relevant particulars thereof). 12. The proof in support of my aforesaid claim/ right/ dispute/ defence is as under : - I have have not applied for legal aid or advice previously, if yes, state the content or substance 13. thereof or the result thereof (if any advice has been received, please disclose the same).
