STATEMENT OF FINANCIAL GIVE DETAILS CIRCUMSTANCES CORPORATION FILE

EMPLOYEES’ COMPENSATION DIVISION LABOUR DEPARTMENT STATEMENT OF
STATEMENT ON RESTITUTION
VICTIM IMPACT STATEMENT

PROJECT NAME NJDOT SCOPE STATEMENT TSM LIMITED SCOPE FINAL
INFOSTMT INFORMATION STATEMENT ASSOCIATIONS INCORPORATION ACT
2 DEXIA SENT THE FOLLOWING STATEMENT TO

	Statement of Financial	Give Details
	Circumstances - Corporation	File Number:
Federal Court of Australia Federal Circuit Court of Australia	Federal Court and Federal Circuit Court Regulation 2012 Subparagraph 2.15(2)(a)	File name:
		Date lodged:

Cross boxes where applicable - type or print clearly providing all details required
Attach an extra page if you need more space for any of the details requested

Notice to applicant

Use this form to provide information about the financial circumstances of a corporation in support of an application to defer payment of court fees on the grounds that, considering those circumstances, it would be oppressive or otherwise unreasonable to require payment of the fee at the time it is required under the Regulation.

If this information is provided in relation to an existing proceeding, it will assist if you include the file number and file name (eg Smith Pty Ltd v Commonwealth of Australia) in the appropriate fields at the top right hand corner of this page.

In considering the application the Registrar/Authorised Officer may ask the corporation to provide additional documentary evidence to support the claim. In that case the application will be returned to the corporation with instructions in the ‘Notice of request for more information’ section which appears on page 8.

WARNING

Under the Criminal Code any person who knowingly makes an untrue representation or statement to obtain a benefit or advantage from the Commonwealth is guilty of an offence and, if found guilty, can be fined or imprisoned.

A Details of the corporation
1	Name, Australian Business Number, Australian Company Number or other unique identifier	Corporation’s name ABN/ACN etc

	Registered Office/ Principal Place of Business	postcode

		Name, job title and telephone number of contact person for the Corporation Tel

B Details of the financial position of the corporation

I, (insert name)

of (insert address)

(insert occupation)

declare that to the best of my knowledge and belief the following information is true and that where any estimate is given, it is given in good faith.

I am the Director/Secretary/Manager/Financial Controller/Accountant (cross out incorrect ones -

if none apply, cross out all and insert other position held in corporation below)

…………….……………………………………………………………………………………….

of the corporation shown in section A above and am authorised to make this application and affidavit on its behalf.

2. I have full personal knowledge about the financial situation of the corporation.

A balance sheet and profit and loss statement for the corporation for the last financial year is attached and marked as attachment “A”. These balance sheets were prepared by (insert details) ..………………………………………………........................................ and have been audited by (insert details) ……………………………………………………….........................................OR / have not been audited.

OR (if no balance sheet and profit and loss statement is available)

A balance sheet and profit and loss statement for the corporation has not been prepared for the last financial year. However, the assets and liabilities and profit and loss of the corporation during this period are, to the best of my knowledge, as set out at attachment “A”.

Since the end of the last financial year the corporation’s financial position has:

*(a) not changed from that set out in attachment “A”.

*(b) changed from that set out in attachment “A” in the following way (explain how the corporation’s financial position has changed):

The corporation will pay its legal costs (explain how the corporation will pay its solicitors’ legal costs)

I believe that the corporation would suffer financial hardship if it had to pay the filing/setting down/hearing fee in this matter, given the corporation’s financial status, as set out above.

(add any additional relevant matters to establish financial hardship)

This is “attachment A” referred to in the details of the financial position of the corporation shown in Section A above made on its behalf by (insert name of person making application and affidavit on behalf of the corporation)………………………..………………………………………………………………..

on the day of 20 .

Assets and liabilities for the corporation of the last financial year

ASSETS

Current assets	Amount last financial year (insert year) …………………………….
Cash (give details)
Investments (give details, eg, bonds, debentures, shares, options)
Receivables (give details, eg, trade debtors, bills of exchange)
Inventories (give details, eg, raw materials, work in progress, finished goods, land held for resale)
Other current assets (give details)
Non current assets
Receivables (give details, eg, trade debtors, bills of exchange)
Investments (give details, eg, bonds, debentures, shares, options)
Inventories (give details, eg, raw materials, work in progress, finished goods)
Property, plant & equipment (give details, eg, land and buildings, plant or equipment)
Intangibles (give details, eg, good will, trade marks, patents, licences)
Other non current assets (give details)
Total assets	$

LIABILITIES

Current liabilities	Amount last financial year (insert year) …………………………….
Creditors and borrowings (give details, eg, bank overdrafts, bank loans, debentures, bills of exchange, trade creditors, lease liabilities)
Provisions (give details, eg, dividends, taxation, employee entitlements)
Other (give details)
Non current liabilities (give details, eg, bank loans, debentures, other loans, trade creditors, lease liabilities, employee entitlements)
Total liabilities	$

Profit and loss statement of the corporation for the last financial year

Item	Amount last financial year (insert year) …………………………….
Operating profit (or loss)
Income tax attributable to operating profit (or loss)
Operating profit (or loss) after income tax
Profit (or loss) on extraordinary items
Income tax attributable to profit (or loss) on extraordinary items
Profit (or loss) on extraordinary items after income tax
Operating profit (or loss) on extraordinary items after income tax
Outside equity interests in operating profit (or loss) and extraordinary items after income tax
Retained profits (or accumulated losses) at beginning of financial year
Aggregate amount transferred from reserves
Total amount available for appropriation
Dividends provided for or paid
Aggregate amount transferred to reserves
Other appropriations
Retained profits (or accumulated losses) at end of financial year	$

NOTES:

A statement must be made below giving details (particulars and the total amount of each item) of each of the items credited as revenue or expenses (as the case may be) in determining the operating profit or loss in the following categories:

Item of profit (or loss)	Amount last financial year (insert year) …………………………….
Dividends
Interest
Material profits (or losses) arising from the sale of non-current assets
Material increases (or decreases) arising from re-evaluation of non-current assets
Material transfers from (or to) provisions
Abnormal items
Interest
Bad or doubtful debts
Depreciation of particular assets

C Affidavit verifying (to be signed in the presence of the witness)

I swear/affirm (cross out incorrect one) that:

I am the Director/Secretary/Manager/Financial Controller/Accountant (cross out incorrect ones – if none apply, cross out all and insert other position held in corporation below)

…………………………………………………… of the corporation shown in Section A above and am authorised to make this affidavit on behalf of that corporation.

I have read this statement and the details and other information attached to it.
The facts in it that are within my personal knowledge are true.
All other facts are true to the best of my knowledge, information and belief and that where any estimate is given, it is given in good faith.
I have disclosed all relevant financial information.
I am aware that it is an offence to provide information or a document in connection with this application that is false or misleading.
I will notify the Court Registry if there are any changes to the corporation’s circumstances that alter the information given in this statement while the Court is dealing with the corporation’s case.

Signature Sworn/affirmed

Place : Date / /

Before me (signature of witness) Full name of witness (please print)

Justice of the Peace Other authorised person specify

This application was prepared by: applicant lawyer

(print name if lawyer)

Court Use Only

Notice of request for more information

Having considered the corporation’s application, the Registrar/Authorised Officer requests the corporation to provide documentary evidence and/or additional information about the corporation’s income, assets and liabilities to support its claim

In particular, it will need to provide the following:

The documents listed above should be provided within 14 days of the date on which this notice was issued. The corporation can provide the originals or photocopies to the Court attached to the back of this application.

/ /

Signature of officer date issued

Authorised by Deputy Registrar (FCA)/Principal Registrar (FCC) 130513

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