Approved form AF2002-165

made under the
Workers Compensation Rules 1938

Workers Compensation Rules 1938— Form 40
(see r 49, 50 and r 51 (3))
Application for investment and application of sum paid into court under the Act, schedule 1, clause 6
(Heading as in præcipe for payment into court.)
TAKE NOTICE, that I (name and address of applicant) intend to apply to the Magistrates Court at Canberra on				, at 			, on behalf of myself and of		    (specify the persons on whose behalf the application is made), as dependants of A.B., for an order for the investment and application of the sum paid into Court in this matter, and for the allotment of the same between the dependants of A.B.
To the best of my knowledge and belief the persons interested in the sum as dependants of A.B. are—
[state dependants, with their ages and relationship to deceased worker, and places of residence.]
I intend to apply for an order for the investment and application of the said sum, and for the allotment of the same between the dependants of the said A.B. as follows:
[state how applicant wishes the sum to be dealt with.]
or in such other manner as the Court in its discretion thinks fit for the benefit of the persons entitled to it under the Workers Compensation Act 1951, and for consequential directions.
Dated:
(Signed)
To the Registrar of the Magistrates Court and [to any other parties interested, where the application is made on behalf of some only of the parties interested.]

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