File Number

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	ACT CIVIL AND ADMINISTRATIVE TRIBUNAL

DEBT APPLICATION- 
CIVIL DISPUTE

APPLICANT’S DETAILS	
Name	 	
Address line 1	
 	
Address line 2	
 	
Telephone	                                                                    Fax:                                       
Email:	
If a corporation:

ACN/ABN

Address of registered officer/public officer		
		
APPLICANT’S REPRESENTATIVES DETAILS (IF ANY)	
Name

Address line 1	
 	
Address line 2	
 	
Telephone	                                                                    Fax:                                       
Email:	
RESPONDENT’S DETAILS	
 Name		
Address line 1		
Address line 2		
If a corporation:

ACN/ABN

Address of registered officer/public officer		
		
Telephone	                                                                    Fax:                                       
Email:	

Grounds of application (set out briefly the grounds of the application)	

	

	

	

	

	

	

	

	

	

Previous attempts to resolve the dispute 	
*The applicant and the respondent have attempted to resolve their dispute in the following way:	

	

	

	

	
	
*The applicant and respondent have made no prior attempts to resolve their disputes	
DETAILS OF AMOUNTS CLAIMED	
Amount	 Reason claimed	
 	Fee for commencing proceedings	
	Charges and out-of-pocket expenses	
	Amount of debt claimed	
	If any other amount claimed- specify amount sought	
	Particulars of Interest:
Interest to be determined by the Tribunal is claimed in accordance with the Court Procedures Rules 2006.

Period(s) for which interest is claimed

Contractual Interest is Claimed:

Period(s) for which interest is claimed

Total amount of interest accrued to date	
	TOTAL AMOUNT OF APPLICATION	

Applicant’s signature			Date		

INFORMATION ABOUT DEBT APPLICATIONS

This Application form should be used for applications to the ACT Civil and Administrative Tribunal (the ACAT) for debt applications. 

A ‘debt application’ is an application to recover a debt. You can also recover interest owing on the debt.

Other applications should be lodged in person between the hours of 9am and 4.30pm at the ACAT, Level 4, ACT Health Building, 1 Moore Street, Canberra City or by mail to GPO Box 370, Canberra ACT 2601 or by fax to (02) 6205 4855