PERSONAL REPRESENTATION FORM

NAME:__________________________________________________________

ADDRESS: ______________________________________________________

CITY: _________________________________ POSTAL CODE: ___________

PHONE: (home) _________________ (work) _________________________

I AM THE: ___ PLAINTIFF ___ DEFENDANT

CASE NAME: _____________________________________________________

FILE NUMBER: ______________________ TODAY’S DATE ______________

ACKNOWLEDGEMENT

____            I have been advised by the staff of the Prothonotary’s Office to seek

(initials)            legal advice from a qualified member of the Nova Scotia Bar Society.

____            I understand that if I do not obtain legal counsel that there are risks

(initials)            involved in pursuing a court action without legal representation.

____            I do not hold the Prothonotary’s office responsible for any of the

(initials)            documentation or information I received while filing this action on my own.

____            I have been given the phone number for Nova Scotia Legal Aid,

(initials)            Halifax 420-6583 ; Dalhousie Legal Aid Service 423-8105; the Lawyer Referral Service and Legal Information Society of Nova Scotia (455-3135) and have been advised of the services provided by each.

Please Note: The information on this form is required for all self-represented individuals before Nova Scotia Supreme Court and Nova Scotia Court of Appeal.

January 2009