Form 5	Application to review a family violence order or registered order
Family Violence Act 2016
(see pt 6 or s 200A)	
In the Magistrates Court of the Australian Capital Territory

FVO ........ /........

............................................................................................................(full name)
Applicant
............................................................................................................(full name)
Respondent

Order type: 		Final / Registered
	(Circle applicable order)
	□	I am a protected person under the original order

	□	I am the applicant for the original order but not a protected 			person under it

	□	I am the respondent to the original order

	□	Other (please specify your interest in the original order)
(Tick if applicable and for ‘other’ attach details of your interest)

I,...............................................................................................................(full name), apply to have the original order, dated ................................................................., reviewed, and seek the following orders:

	□	That leave be granted by the Court to bring an application for
		review.  (If applicant for review is respondent to the original order or ‘other’)

	□	That the original order be set aside and replaced with a new 
		order in the following terms:
................................................................................................................................
................................................................................................................................
................................................................................................................................
................................................................................................................................
(attach additional page if necessary)
	□	That the original order be revoked.

This order is sought for the following reasons:
................................................................................................................................
................................................................................................................................
................................................................................................................................

...................................................................	Dated: ______ /______ /20______
(Signature of applicant or applicant’s solicitor)

................................................................................................................................
(Name of applicant or applicant’s solicitor)
□ tick if applicable