File Number

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	ACT CIVIL AND ADMINISTRATIVE TRIBUNAL

APPLICATION FOR DEFAULT JUDGEMENT- 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:	

To the Registrar:

The applicant applies for judgment against the respondent.

Amount stated in claim
Fee for commencing proceedings:	$	
Charges and out-of-pocket expenses:	$	
Amount claimed:	$	
Particulars of interest:
•	period(s) for which interest is claimed:
•	rate(s) at which interest is claimed:
•	total interest accrued to date:	

$	
Total:	$	

Debt declaration
Fee for commencing proceedings:	$	
Charges and out-of-pocket expenses:	$	
Total amount in relation to which declaration is sought:	$	

Amount not stated in claim—damages to be assessed
The applicant applies for judgment in relation to—
the whole application.
the following part of the application:
(set out the part of the claim for which judgment is sought)

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Date:___________________________

Name:_________________________________________________________

Signature:______________________________________________________