Approved form AF2002-178

made under the
Workers Compensation Rules 1938

Workers Compensation Rules 1938— Form 53
(see r 57 (10))
Notice to be given to worker intending to cease to reside in Australia
[Heading as in award or memorandum.]
Take Notice, that if you desire to obtain payment of the weekly payments payable to you under the award [or memorandum] (a copy of which is annexed) while you are residing out of Australia, you must, at intervals of 3 months from the date up to which such payments have been made, submit yourself to examination by a medical practitioner in the place where you are residing, and produce to him or her the copy of the certificate of the medical referee and the certificate of identity annexed; and you must obtain from such medical practitioner a certificate in the form annexed that he or she has examined you, and that your incapacity resulting from the injury specified in the certificate of the medical referee continues; and such certificate must be verified by the medical practitioner by declaration in your presence before any person having authority to administer an oath.
You must also attend before some such person and make a declaration in the form annexed that you are the same person as mentioned in the copy of the certificate of the medical referee and in the certificate of identity annexed, and in the certificate of the medical practitioner by whom you have been examined, producing to such person the copy and certificates.
You must then forward to me, at my office, at Canberra, the certificate of the medical practitioner by whom you have been examined, and your declaration, together with a request for transmission to you of the amount of the weekly payment due to you, specifying the place where and the manner in which the amount is to be transmitted, according to the form annexed, which request must be signed in your own handwriting.
In the event of your death while residing out of Australia, your representative must, in order to obtain payment of the arrears due to you, forward to me, at my office, at Canberra, a certificate of your death, and documents showing that they are entitled to such arrears, verified by declaration before a person having authority to administer an oath, with a request for payment of the arrears, specifying the place where and the manner in which the arrears are to be transmitted to them.
The expression your representatives means—
	(a)	if you leave a will, the executors of the will; or
	(b)	if you die intestate, the persons who are according to law entitled to your personal estate; and payment of the arrears may be made to those persons without the production of letters of administration.
Dated:
Registrar of the Magistrates Court.
To A.B.
of [address and description.]

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