Form 5	Application to review order
Domestic Violence and Protection Orders Act 2008, s 91
In the Magistrates Court of the Australian Capital Territory

DV/RO/WO ……. /………………

APPLICANT			.........................................................................

RESPONDENT		...................................................................

I, (name)  ………............................................................................................................
Pursuant to Part 11 of the Domestic Violence and Protection Orders Act 2008 apply to have Order of the Court dated ............................... in these proceedings reviewed.  
UPON THE GROUNDS THAT:

…………………………………………………………………………………………………….

…………………………………………………………………………………………………….

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Signature

If you are the respondent or someone else with sufficient interest in these proceedings, you must also apply for leave before your application may be determined.  

This may be determined by the Court at the same time as your application.
Leave required? 	□ Yes	□ No  (if yes, please complete form below)

I, (name)  ………….....................................................................................................
Pursuant to Part 11 of the Domestic Violence and Protection Orders Act 2008 seek leave to apply to have the Order of the Court dated ............................... in these proceedings reviewed.
LEAVE APPLIED ON THE FOLLOWING GROUNDS:

…………………………………………………………………………………………………

…………………………………………………………………………………………………

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Signature

Dated this ...................................... day of .......................................................... 20…….

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Deputy Registrar