File Number

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	ACT CIVIL AND ADMINISTRATIVE TRIBUNAL

STATEMENT OF CHARGES AND OUT OF POCKET EXPENSES 
CIVIL DISPUTE
		
	This statement is to be attached to the Civil Dispute Application/Declaration to commence proceedings before the Tribunal		

Date incurred	Amount incurred	Nature of charge or 	Reason for incurring expense	
	out-of-pocket expense		

 	

 	

	

	

	

	

	

	TOTAL AMOUNT OF APPLICATION	

Applicant’s signature			Date