Form 5.16	Court of Appeal—application to registrar for leave to appeal out of time against conviction or sentence
Court Procedures Rules 2006
(see r 5506 (Appeals to Court of Appeal—application for leave to appeal out of time against conviction or sentence))
In the Supreme Court of the Australian Capital Territory
Court of Appeal
Criminal jurisdiction
No ACTCA		of (year)

Appeal against *[conviction/sentence imposed by Justice (name of judge)]
(No SC		of (year))

(name)
Applicant

Director of Public Prosecutions
Respondent

1.	The applicant applies for leave to appeal out of time against the *[conviction recorded on (date)/sentence imposed by Justice (name of judge) on (date)].
	(if r 5506 (4) applies)
*2.	[The applicant wants to present the applicant’s case in writing.]
	(if r 5534 (4) applies)
*3.	[The applicant *[want/does not want] to be present at the hearing.]

Supporting affidavit
This application is supported by the affidavit of (name) *[sworn/affirmed] on (date).
(The affidavit that you intend to rely on must be filed in the Court with the application (see r 5506).)
(You must, not later than 5 days after the application is filed, serve the following on the Director of Public Prosecutions:
	(a)	a sealed copy of the application;
	(b)	a stamped copy of the accompanying affidavit;
	(c)	a stamped copy of the draft notice of appeal (see r 5508).
If you are in custody and not represented by a solicitor, you may serve the documents on the Registrar for service by the Registrar on the Director of Public Prosecutions (see r 5533).)

Applicant’s address for service of documents
(set out applicant’s address for service)
(if represented by a solicitor the following information may be given)
*Document exchange box no:
(if postal address different from address for service)
*Postal address:
*Fax:
*Email address:
Date:
(signature of applicant/applicant’s solicitor)
(name of applicant/ applicant’s solicitor)

*omit if, or whichever is, inapplicable