Ip Application Form and Consents Jan 2019

This document is an application form for legal services from the Legal Aid Board to assist with an application for asylum, subsidiary protection, or permission to remain in Ireland. The form requests personal information and details about the applicant's protection application status and process. It includes a declaration authorizing the Legal Aid Board to act as the applicant's solicitor and requesting information related to the protection application be provided to the Board. Consent letters are attached for the applicant to sign authorizing information sharing with the Board.

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Ip Application Form and Consents Jan 2019

Uploaded by

hajimuktar66

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Application for Legal Services

International Protection and Permission to Remain

How to complete this form:

 This form is for applying to the Legal Aid Board for legal services to help with your application for
asylum, subsidiary protection, or permission to remain in Ireland.
 Please write clearly and answer all questions that apply to you.
 Incomplete forms may be returned and may delay processing your application.
 If you need help, a member of the Board’s staff will help you to fill in this form.
 Fill in this form and return it to the relevant law centre (Dublin, Cork or Galway).
Law Centre (Smithfield) Law Centre (Pope Quay) Law Centre (Galway Seville House)
48/49 North Brunswick Street North Quay House Seville House
Georges Lane Pope’s Quay New Dock Road
Dublin Cork Galway
D07 PE0C T23 HV26 H91 CKV0
Freephone 1800 23 83 43 Freephone 1800 20 24 20 Freephone 1800 50 24 00
Tel (from mobile): 01 6469600 Tel (from mobile): 021 4551686 Tel (from mobile): 091 562480
 When we receive this fully completed form, we will assign a solicitor and caseworker or private
solicitor to your case. We will tell you who they are and how you can contact them. From then on
you can contact your solicitor or caseworker if you have any queries.
1. PERSONAL INFORMATION
You must complete this part fully: (If you suffer from a disability or have any access needs in relation to our
services please detail this on a separate page and attach to this form.)

First Name Surname

Date of Birth Gender Male Female

Marital Status Single Married Nationality

Contact phone
Language
Number
Interpreter
Email address Yes No
required
Current
Address (You
must notify us
immediately if you
change address)

Eircode

2. YOUR APPLICATION FOR INTERNATIONAL PROTECTION IN IRELAND

Details:
Personal reference no Date issued
Please give details of any other family members living in Ireland. If married please give spouse
details.
Name Relationship to you
(Family Member 1)
Is this person seeking Personal reference
international protection? number
Name Relationship to you
(Family Member 2)
Is this person seeking Personal reference
international protection? number
*If there are additional family members, please list them as above on a separate page and attach to this form
Current status of your protection application (Please tick):
I have not filled in or submitted my I have submitted my questionnaire to the IPO
questionnaire to the IPO yet (if you have been given an interview date please
note it here):
I have done my interview with the IPO* I have received a negative decision on my
appeal from the IPAT (please write the date of
the decision here):
I have received a Dublin III Transfer decision I have received a Deportation order (please
from the IPO/IPAT (please write the date of the write the date of the order here):
decision here):
*For clients registering for first time after their interview:
Have you received a recommendation on your International Protection
Yes No
Application?
If the answer is “Yes”, please state:
The date the letter was issued to you / /20
Details of the decision made

Please sign the attached consent letter regarding your legal representation

3. STATEMENT OF INCOME AND ASSETS

If you do not own any property of any kind anywhere in the world or have any savings you do not need to
complete a statement of means and assets. Please tick the box below.

My only source of income is a direct provision allowance and the value of my assets of any kind
(other than my home) does not exceed €4,000.

If you cannot tick the above box, you need to fill out the normal Application for Legal Services form which is
available from the law centre.

DECLARATION – Please read carefully before you sign

1. I confirm that all the information I have given on this form is correct and I have not deliberately left
anything out.
2. I understand that if it is later found that I gave incorrect information on this form or have left out any
information asked for on this form, the Legal Aid Board can take away my legal aid/advice and I can
be held liable for the cost of the service it provided up until that point.
3. I give the Board permission to obtain any details or other information about my case which the
Board might require.
4. I understand that the Board may contact the Department of Employment Affairs and Social
Protection to obtain or verify any details of payments they make to me or any other information
about my means that they might have on file.
5. If any details on this form change I will inform the Board.
6. I understand that the Board may re-assess my means and capital at any time while it is providing
me with legal services, until my case is concluded and my file is closed. They may, based on the
outcome of that re-assessment, decide to withdraw my legal aid/advice.
Signed: Date:

Data Protection and Freedom of Information

The Legal Aid Board will treat all information and personal data you give as confidential. The Board
will only disclose it to other people or bodies according to the law.
To Whom It May Concern

Re:
Personal reference number:

I, , of , hereby authorise and instruct the Legal Aid

Board, Law Centre (Smithfield), 48/49 North Brunswick Street, Georges Lane, Dublin D07 PE0C
to act as my solicitors in relation to my application for International Protection/ Permission to
Remain in the State.

I request that all information and documentation, including translations of any documents in your
possession, power or procurement pertaining to my application for International Protection /
Permission to Remain in the State be furnished to the Legal Aid Board, Law Centre (Smithfield),
48/49 North Brunswick Street, Georges Lane, Dublin D07 PE0C.

Signed: ______________________

Dated: ______________________
To Whom It May Concern

Re:
Personal reference number:

I, , of hereby authorise and instruct the Legal Aid

Board, Law Centre (Cork North), North Quay House, Pope’s Quay, Cork T23 HV26 to act as my
solicitors in relation to my application for international protection/ permission to remain in the State.

I request that all information and documentation, including translations of any documents in your
possession, power or procurement pertaining to my application for international protection/
permission to remain in the State be furnished to the Legal Aid Board, Law Centre (Cork North),
North Quay House, Pope’s Quay, Cork T23 HV26.

Signed: ______________________

Dated: ______________________
To Whom It May Concern

Re:
Personal reference number:

I, , of , hereby authorise and instruct the

Legal Aid Board, Law Centre (Galway), Seville House, New Dock Street, Galway H91 CKV0 to act
as my solicitors in relation to my application for International Protection/ Permission to Remain in
the State.

I request that all information and documentation, including translations of any documents in your
possession, power or procurement pertaining to my application for International Protection /
Permission to Remain in the State be furnished to the Legal Aid Board, Law Centre (Galway),
Seville House, New Dock Street, Galway H91 CKV0.

Signed: ______________________

Dated: ______________________