File Number

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	ACT CIVIL AND ADMINISTRATIVE TRIBUNAL

RESPONSE- 
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:	

Admission of liability
I admit liability 
•	in whole or 
•	in part 
and agree to the entry of judgment on the following terms:
Judgment is to be entered in the amount of: $_________________
The following amount is paid into court: $___________________
The amount of the judgment is to be paid on or before
_____________________________________________________________________

The amount of the judgment is to be paid by instalments on the following terms
_____________________________________________________________________
The following orders are to be made:
_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

If liability is not admitted
Disputed claim
I dispute the applicant’s claim on the following grounds (please attach page if insufficient space):
_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________
If the respondent has a counterclaim or set-off
Counterclaim [and set-off]
The following counterclaim and set-off is made: $_______________
Set out briefly the grounds of the counterclaim and set-off
_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

Date:

Signature of respondent or respondent’s representative

Name of respondent or respondent’s representative:___________________________