I, [full name], the applicant, give notice that I am applying for [special] leave to appeal to the Court against [state particulars of the decision against which you wish to appeal, including the date on which, and the court where, it was given].
I am seeking to appeal against [state whether you wish to appeal against all or part of the decision; if just part, identify that part].
I am making my application for [special] leave under section [number] of the [name] Act [year].
*I applied for leave to appeal to the Court of Appeal in the [name] Court, but that application was declined on [date].
The specific grounds of my appeal are [state grounds].
The Court of Appeal should grant me leave to appeal because [state reasons].
The judgment I seek from the Court of Appeal, if leave is granted, is [specify the form of judgment you seek].
I rely on the following affidavit(s) in support of my application for leave:
[list deponents, and the date on which each swore his or her affidavit].
*I have applied for legal aid.
|*Insert whichever is applicable.|
Dated this [date] day of [month] [year].
Signature of appellant or
appellant’s solicitor or
My address for service is [insert address]:
In the case of an application for leave to cross-appeal, modify this form as appropriate.
An application for leave must be accompanied by—
a copy of the decision to which the appeal relates; and
a copy of any separate reasons for the decision (if available); and
if that decision was given on appeal, a copy of every decision previously given in the proceeding on matters of relevance to the appeal; and
a copy of any separate reasons for every decision referred to in paragraph (c); and
any affidavit relevant to the application.