Counselling And Report Fee Invoice V2 - Form 5 Page 2

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Section 5: Counsellor / Report Writer Certification
I,
certify that:
(name of person that authored the report / provided counselling to applicant)
I wrote and signed the report referred to in this invoice
.
(delete clause if no report filed with invoice)
The counselling session(s) claimed in this invoice was
:
(tick box for relevant clause)
previously authorised by the Tribunal by letter/notice dated
/
/
not previously authorised by the Tribunal.
The counselling sessions detailed in this invoice were provided by me
(delete clause if no counselling claimed in
.
invoice)
I signed this invoice in the column headed ‘signature of counsellor’ at the conclusion of each counselling
session claimed in this invoice
.
(delete clause if no counselling claimed in invoice)
The applicant signed this invoice in the column headed ‘signature of applicant’ at the conclusion of each
counselling session claimed in this invoice
.
(delete clause if no counselling claimed in invoice)
I understand that the filing of this invoice does not guarantee payment of all or part of the amount claimed,
and that the amount awarded for expenses is at the discretion of the Tribunal.
Counsellor’s signature
Counsellor’s occupation
Dated:
2 of 2

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