Please provide your contact details and information detailing your legal costs or fine amount. The Board of Trustees require invoices from lawyers, or details of court fine payment. All payments will be made by cheque to the lawyer and/or court subject to availability of donated funds and to approval by the Forest Defender Fund Trustees.

Name:.........................................................

Contact Details:.....................................................

Address:.....................................................

.....................................................................

....................................................................

Email:........................................................

Phone number:.......................................

Tick a box that best describes your income:

[ ] Under $10 000

[ ] $10 000 - $30 000

[ ] $30 000 - $50 000

[ ] over $50 000

Details of charges, fines and/or court action:

Signature of applicant:........................................

Date: ........../........./...........