Form 3.53	Small Claims Court—application for default judgment
Court Procedures Rules 2006
(see r 3757 (Small Claims Court—default judgment))
In the Small Claims Court of the Australian Capital Territory

Application No		of (year)

(name)
Applicant

(name)
Respondent

To the Registrar:
The applicant applies for judgment against the respondent.
*Amount stated in claim
Fee for commencing proceedings:	$	
Charges and out-of-pocket expenses:	$	
Amount claimed:	$	
Particulars of interest:
•	period(s) for which interest is claimed:
•	rate(s) at which interest is claimed:
•	total interest accrued to date:	

$	
Total:	$	
*Debt declaration
Fee for commencing proceedings:	$	
Charges and out-of-pocket expenses:	$	
Total amount in relation to which declaration is sought:	$	
*Amount not stated in claim—damages to be assessed
The applicant applies for judgment in relation to—
*the whole application.
*the following part of the application:
(set out the part of the claim for which judgment is sought)

Date:
(signature of applicant or applicant’s representative)
(name of applicant or applicant’s representative)
*omit if, or whichever is, inapplicable