Approved form AF2002-139

made under the
Workers Compensation Rules 1938

Workers Compensation Rules 1938— Form 14
(see r 21)
Notice of payment into court in the case of death
[Heading as in Request for arbitration.]
TAKE NOTICE—
That the respondent, C.D.			    , has this day filed with me a notice (copy of which is sent herewith) that he or she admits his or her liability to pay compensation in this matter, and has paid into Court the sum of	                                in satisfaction of such liability.
[Or
TAKE NOTICE—
That the respondent, C.D.			    , has this day filed with me a notice (copy of which is sent herewith) that he or she denies his or her liability to pay compensation in this matter, but that he or she has paid into Court the sum of			in satisfaction of the claim.]
If you are willing to accept the sum so paid into Court in satisfaction of the compensation payable in this matter, you must send to the Registrar of this Court, and to C.D.			    , and to the other respondents [or, where this notice is sent to a respondent, to the applicant and other respondents], a written notice forthwith by post, or leave such notice at the office of the Registrar, and at the residence or place of business of C.D.			, and at the residence or place of business of each of the other respondents [or of the applicant and each of the other respondents.]
If you and all the other respondents [or, If you and the applicant and all the other respondents] send such notice, and agree as to the apportionment and application of the said sum of			, the Court will, on application made to it, make an award for such apportionment and application, and you will be liable to no further costs.
If you and all the other respondents [or, If you and the applicant and all the other respondents] send such notice, but do not agree as to the apportionment and application of the said sum of			, the arbitration will be proceeded with as between you and such other respondents [or, as between the applicant and yourself and such other respondents.]
In default of such notice being sent by you and all the other respondents [or, by the applicant and yourself and all the other respondents], the arbitration will be proceeded with; and if no greater amount than the said sum of			is awarded as compensation, the parties who do not send such notice will be liable to be ordered to pay the costs incurred by the respondent C.D.,			subsequent to the receipt by such parties of this notice, and also any costs incurred subsequent to the receipt of this notice by any parties who send notice of their willingness to accept the said sum of		         in satisfaction of the compensation payable in this matter.
Dated:						
Registrar of the Magistrates Court.
To the applicant, A.B.						
[or, To the respondent, G.H.]
(or as the case may be).

Endnotes
1	This form was originally in the Workers Compensation Rules 1938, schedule 1.  Under amendments made by the Legislation (Consequential Amendments) Act 2001, the form was omitted from the rules and became a form approved under the rules, rule 89 (see amdt 1.2805, amdt 1.2807).
2	This republication includes amendments made under the Legislation Act 2001, part 11.3 (Editorial changes).

©  Australian Capital Territory 2002