Supplementary Application Form
General Negligence, Breach of Contract, Breach of Statutory Duty
(excluding Tripping, Employer’s Liability and Road Traffic cases)
CL 5
1 April 2015
Section A : Applicant’s details
National Insurance Number
Section B : Legal Advice and Assistance
Does the applicant qualify for Advice and Assistance? Yes No If so, have you availed of this in order to accumulate evidence and adequately prepare the Legal Aid
application? Yes No If not, please provide an explanation:
• This document forms part of the Legal Aid Application (Form A 1) and must be completed by the applicant’s solicitor. • If any section of this document or Form A 1 is incomplete, the application and all accompanying papers will be returned
to the solicitor. If the applicant qualifies, Advice and Assistance should be utilised to gather the relevant information and extensions of the normal financial limits should be sought in appropriate cases. The application should not be submitted until all the relevant information has been obtained. If you indicate that further details “will follow”, the application will be returned to you and should be resubmitted when the information is available.
• Legal Aid will be refused if the applicant has failed to establish reasonable grounds for taking, defending or being a party to proceedings, or if it would be unreasonable in all the circumstances to grant Legal Aid.
• If any of the questions in Parts C - D are not relevant state so, to avoid further queries being raised.
Full Name of Applicant Maiden or Other Name Full Name of Minor Address
CL 5 | Page 2 1 Defendants (a) State the correct title of all proposed defendants: (If the proposed
defendant is not an individual or limited company, the full names or title of the persons or entity carrying on the business or representing the organisation must be furnished)
(b) If you have named more than one defendant have Bullock Letters been sent?
2 Minor Plaintiffs (a) Is the plaintiff a minor?
(b) If so, is he/she capable of tendering evidence?
(c) If so, you must attach a copy of his/her statement. Have you done so? 3 Provide full details of the negligence and/or breach of statutory duty which
will be alleged: (Please use Continuation Page if necessary)
4 (a) Are there any witnesses?
If so, you must attach copies of their statements. Have you done so?
5 Are photographs available?
If so, the originals, or clear copies, capable of being photostated, must be attached. If submitting original photographs, ensure that the applicant’s full name and address are clearly written on the reverse side. Has this been done?
6 (a) Is any expert evidence available (apart from medical experts)? (b) If so, provide details: (Please use Continuation Page if necessary)
(c) If not, do you intend to engage any expert witnesses?
If so, provide full details: (Please use Continuation Page if necessary)
Is an engineer’s report necessary?
(a) If so, has the defendant agreed to grant inspection facilities prior to the issue of proceedings?
(b) If the defendant has not agreed, a formal written request for pre-proceedings inspection facilities should be made. Have you done so and attached a copy of your request and the defendant’s response?
7 Is any documentary evidence available?
If so, have you attached copies?
Section C : Details of evidence
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Section D : Details of injuries sustained and medical treatment
Provide a detailed description of injuries: (Please use Continuation Page if necessary)
State date, time and venue of first medical treatment:
(a) Was there a delay in seeking medical treatment?
(b) If so, provide an explanation:
(Please use Continuation Page if necessary)
Yes No
Have you attached copies of all available
CL 5 | Page 4
Section E : Solicitor’s general observations
In your view what are the prospects of successfully establishing liability?
Section E : Solicitor’s general observations (continued)
Signed Solicitor Date
Data Protection Act 1998 – Access to Personal Data - The Legal Services Agency Northern Ireland (LSANI) will use the personal information provided by you or on your behalf in accordance with the Data Protection Act 1998 and for the purpose of its functions under the Legal Aid Legislation. You have the right to make a formal request in writing to see the personal information we hold about you, to inspect it and to have it corrected if it is wrong. LSANI may receive information about you from certain third parties (for example, some government departments and agencies), or give information to them. However, we will not pass on information about you unless the law allows us to do so.
I confirm that I have personally checked the foregoing and am satisfied that all sections have been fully and accurately completed and that all the enclosed documents are clear and legible. I understand that if a Legal Aid Certificate is granted I have a duty to keep the case under review and to keep the Legal Services Agency informed of any material development which may adversely affect the continuation of Legal Aid.
CL 5 | Page 6
