Cole Cr Form Number 6 (version 3) (Queensland Civil and Administrative Trbunal Rules 2009 (rule 60) Request for decision by default — minor civil dispute — minor debt Rofor'to the attached instructions prior to filing out this form, Gees This form must be ladged at the registry where ‘Case number: your application was lodged. Tals fied Rogistry: GUL apn ESE OO isa AOR yeas) Applicant Respondent RUE u=ae ace Case number (if known): Registry at which the original minor debt application was lodged. PERU cel t= ane e RLLSUSs Oa I want the tribunal to make a decision in default of the respondent filing a response to my application for payment of a debt or liquidated demand of money. CHECKLIST | have completed all pars to this form Ihave completed and signed every page of Part B (or have already fled a Form 9 Affidavit of service) | have complated and signed Part C Including the final page 1 nave sched supporing documentation wher reqed [1 erred o proceed wi is appieation Request for decision by default minor cl ispute—minor debt page fof 5 For mare information on QCAT: Call 1300 753 228 o visit www qe govauNita Uikoms sano "Note: If you have already fled a Form 9 - Affidavit of service then you do not need to complete Part B. 4 (insert tll name of person making affdavt) of (insert residential or business adress, or place of employment) Postcode state on oath / solemnly and sincerely atfirm and declare onthe Zz 7 20 at Jam pn, served {insert name of person or entiys served) a copy of Tinsare name of documents) filed on Z 720 at the Queensiand Civil and Administrative Tibunal (insert ual adress) AS FOLLOWS (complete sarce dots inthe relevant pars below - 81, 82 or B3) PARTB1 PERSONAL SERVICE Note: personal service Is required for applications for minor evil dispute - minor debt claims. 4. delivered the copy to [] him her them personally at inset adress) Postcode 2. | identified the person served by (iieor means of aniowton) Person making adavi to sin Person taking the afdavitto sign Request for decision by default minor cl depute - miner debt—page 2 of 5 For more information on QCAT: Call 1300 753 228 o vist www.gcatqld.gov.auOtay ae ole Coe eft the copy atthe company's registered office, namely Postcode | posted the copy tothe company’s registered office, namely Postcode | served the copy otherwise in accordance with section 108X of the Corporations Act 2001 (Commonwesith), namely Tnser mathod af ervce) Oe MO ee | served the copy in another way in accordance withthe service practce direction, namely (insert method of srvice) | served the copy in accordance with the tribunar’s direction, namely by (inser mthod of service) Person mating afiavito sin ‘Person taking the atavito sign Request for decison by default miner evi dispute ~ minor debt— page 3of § ee For more information on QCAT: Call 1300 753 228 or vist vwyn.cat.qi.gov.auGIRCM aa) Loos (peor il name of persan making affavt) of (insert residential or business ares, or place of employment) Postcode state on oath /golemnly and sincerely affirm and deciare: 41. The application against the respondents for $ 18 a debt or liquidated demand cof money, 2. Ihave not received a response tothe application from the respondent, Complete 3 or 4 if you are the applicant: 3. The respondent has not paid the amount ciaimed by me. ‘The amount ofS remains owing to me 4. The respondent has paid the following amounts to me in pat satisfaction ofthe claim. (Complete the table below.) The amount of $ remains owing to me. Complete § or 6 if you are the solicitor/agentidirector of the applicant: 5. Ihave tis day spoken with (insert name and oe of person) be they informed me and | believe that the respondent has not pal the amount claimed by the applicant the person who has custody and control of the records ofthe applicant and ‘The amount ofS remains owing to the applicant 6. | have this day spoken with {insert name and roe of person) being the parson who has custody and control ofthe records ofthe applicant and they informed me and I believe thatthe following amounts have been received from the respondent. (Complete the table below.) The amount of $ remains owing to the applicant 7. Table of payments (f applicable) Date Payment Person mating affidavit to sin Person fekng the afdavitto sign Request or decison by default ~ miner el dspute- minor debt page 4 of 5 ee For mote information on QCAT: Cll 1300 753 228 o vist wwma.qcat. ql. govauDETAILS OF WHAT YOU SEEK FROM THE TRIBUNAL | want the tribunal to order the respondent to pay the amount of $ (insert the amount owing as stated in Part C) | also want to claim interest on the amount owing from the date when the debt became due to the date ofthe tribunal's final decision. Choose from the rate which applic the rate | agreed withthe respondent: %pa oR It there is no agreement with the respondent about th interest o be paid = the Interest wl be determined bythe tribunal "You can ask for interest to be determined by the tribunal at the rata _presarhed by practice direction. You may also referto the interest Ccalcultor avaliable at wirw.courts qld govau, In ither case:- | have calculated the amount ofthe interest up to the date of this application as. $ 1also want to claim these amounts: the fling foo $ CCITEC Confim service fe for electronic fling s ball /sherif/ service fee s ‘Australian Securities and Investments Commission (ASIC) business name extract or company extract search fee ‘The total amount of my claim is: § ‘Swom (or affirmed) by (inst full name) . 7 720 at pice) Inthe presence of Person making affidavit to sion ‘Person taking the afi o sign Commissioner for declarations! eolctor/ Justee ofthe peace Printname Request for decison by default - minor chil dspute—minor debt page Sof 5 For more Information on QCAT: Call 1300 753 228 o Visit www.qeat.qd.gov.aQCAT eee orn! Instructions for completing Request for decision by default — minor civil dispute — minor debt When can you make a request for a decision by default? + Youcan only make a request if (a) no response has been filed within 28 days of service of your application on the respondent, and (©) your claim is for a fixed amount of money. + You cannot get a decision by default if your application, or any part thereof, is for: (@) restitution, (0) 2 declaration that a term of a contract is of no effect, (© avoidance of a policy of insurance under the statutory insurance scheme, or (@) an order for rectification or completion of defective or incomplete work. ‘Supporting documents ‘You must attach all supporting documents to this application if you have not already filed the documents with the Form 3 Application for minor civil dispute ~ minor debt. + Ifyou had a verbal agreement, you will need to file an affidavit providing evidence of this agreement (if you haven't already filed it) PART B AFFIDAVIT OF SERVICE Please complete details of service of the application. You must sign every page. Please note: Part B must be completed by the person who served the application upon the respondent. If another person served the respondent then they must complete a Form 9 - Affidavit of Service. if you have already filed a Form 9 - Affidavit of Service proving service of the application then you do not need to complete Part B, + Ifthe respondent is a company you must attach copy of an ASIC search showing the company name, ACN or ABN and the address for service, + Refer to the Queensland Civil and Administrative Tribunal Rules 2009 and the Queensland Civil and Administrative Tribunal practice directions for service requirements. + Insert your full name and residential or business address or place of employment. + Ifthe entity served is not an individual then you must use the correct name, for example: = acompany name, including the company's ABN or ACN. You must attach a copy of the ASIC Company Extract showing the company's registered office, = a business name regardless of whether its registered. Where the business has an ABN you ‘must inelude this number, You must also attach a copy of the ASIC Business Name Extract showing the business’ registered office. = State agency name, for example a Queensland Govemment department. + Ifyou are serving an application for a minor debt claim you must deliver the copy to an entity personally and in a way that complies with QCAT's practice direction on service. Instructions - Request for deielon by default - minor cl dlspute- miner debt page 1 of 2 For more information on QCAT: Call 1300 753 228 or visit wirw.qcatald.govauInstructions for completing (continued) PART C AFFIDAVIT OF DEBT DETAILS + You must complete Part C and detail the amount outstanding with this application. Interest + You can claim interest at a rate specified under the contract or agreed between you and the respondent. You will need to prove that agreement. + Ifthe rate was in a contract, you will need to attach a copy, or evidence of that agreement to your application (if you haven't already fled it) + Ifa rate has not been agreed or provided in the agreement, you can ask for interest at the rate prescribed by practiced direction. You may also refer to the interest calculator available at www. courts. qid.gov.au SIGNATURE Each page of Part B (if completed) and Part C must be signed. Please sign in the presence of a person who is authorised by the Oaths Act 1867 to take an affidavit: (@) justice, commissioner for declarations or notary public under the law of Queenstand, the Commonwealth or another State, (©) alawyer, (©) a conveyancer, or another person authorised to administer an oath, under the law of the state, the Commonwealth or another state, (@) ifthe affidavit is taken outside Australia — a person authorised to administer an oath under the law of the place in which the affidavit is taken. Important note: Do not use this form if you are applying for an electronic decision by defauit. Requests may be lodged ‘You must lodge the request at the same Magistrates Court or QCAT registry at which you filed the ‘original application. No extra copies of the request and attachments are needed, however you should keep a copy for yourself WARNING ‘Section 216 of the Queensland Civil and Administrative Tribunal Act 2009 makes it an offence for ‘a person to knowingly give the registry documents containing false or misleading information Maximum penalty for such an offence — 100 penalty units. YOUR INFORMATION QCAT collects your contact details for the purposes of compliance with the Queensland Civil and Administrative Tribunal Act 2009 in relation to proceedings in QCAT. QCAT may contact you to seek your assistance in research to assist in the evaluation of the operation of QCAT. You are not obliged to participate in feedback or surveys. If you do participate no identifying particulars will be published. QCAT will not disclose your contact details or any other personal information to a third party unless required by law. Instructions - Request for decision by defaut-minor cl dispute-mier debt page 2 of For mote information on QCAT: Call 1300 753 228 01 visit www.qcat.qd.gov.au