What is this form for?
Use this form to make a claim to the Tribunal.
Completing and submitting this form
3 Check, before submitting this form, that you have answered all questions and signed and dated it.
Note: This form will be returned to you if it is incomplete, unsigned, or undated.
4 Submit this form by post or in person to the District Court closest to your physical address.
Note: If you live in Auckland, there are 5 District Courts: North Shore, Waitakere, Auckland City, Manukau, and Papakura. Full address details for all District Courts can be found at www.justice.govt.nz/tribunals
What happens after you have submitted this form
A copy of this form will be sent by the Tribunal to all other parties (to all the respondent(s)) to the claim.
Part 1: Applicant (you, the individual or organisation making the claim)
If claiming as a trustee of a trust, state that and name all other trustees (if any) of the trust.
Individual's family name(s):
Individual's first name(s):
Organisation's name (if a corporation or unincorporated body of persons, for example, an individual's employer):
Attention (organisation's contact):
Physical address (a physical address is required)
Street or road (number and name):
Rural delivery number:
Suburb:
City, town, or district:
Postcode:
Postal address (if different from physical address)
Street or road (number and name):
Rural delivery number:
Suburb:
City, town, or district:
Postcode:
Contact details
Daytime telephone number:
Mobile telephone number:
Email address:
Note: If your address or contact details change, you must notify the Tribunal immediately.
Do you require an interpreter?
Yes / No
If yes, state the language(s) that you speak:
Part 2: First respondent (the individual or organisation you are claiming against)
Individual's family name(s):
Individual's first name(s):
Organisation's name (if a corporation or unincorporated body of persons, for example, an individual's employer):
Attention (organisation's contact):
Physical address (a physical address is required)
Street or road (number and name):
Rural delivery number:
Suburb:
City, town, or district:
Postcode:
Postal address (if different from physical address)
Street or road (number and name):
Rural delivery number:
Suburb:
City, town, or district:
Postcode:
Contact details
Daytime telephone number:
Mobile telephone number:
Email address:
Part 3: Second respondent (another individual or organisation you are claiming against)
Individual's family name(s):
Individual's first name(s):
Organisation's name (if a corporation or unincorporated body of persons, for example, an individual's employer):
Attention (organisation's contact):
Physical address (a physical address is required)
Street or road (number and name):
Rural delivery number:
Suburb:
City, town, or district:
Postcode:
Postal address (if different from physical address)
Street or road (number and name):
Rural delivery number:
Suburb:
City, town, or district:
Postcode:
Contact details
Daytime telephone number:
Mobile telephone number:
Email address:
Part 4: Applicant's insurance and insurer
Is this a claim that could be covered by your insurer? Yes / No
If you have been, are entitled to be, or have sought to be, indemnified (that is, compensated) by your insurer for any loss caused by or arising out of the act, omission, or event on which the claim is based, complete the following:
Full legal name of your insurer:
Your insurance claim number:
Your insurer’s postal address:
Part 5: Details of your dispute
How much do you want the Tribunal to award you?
(Note: if your claim is for more than $15,000 but is not for more than $20,000 you will need to complete an “Agreement to Extend Financial Limit”
form (Disputes Tribunal form 1A) available at www.justice.govt.nz/tribunals)
What do you claim happened? Include specific details, including relevant dates and locations, of the dispute.
Part 6: Applicant's contact with respondent(s)
Outline what, specifically, you have done to resolve the issue. For example,—
What did the respondent(s) say when you asked the respondent(s) to pay or otherwise resolve the issue?
How did you contact the respondent(s) (for example, by telephone or email)?
On what date did you contact the respondent(s)?
When and how did the respondent(s) reply?
How is your claim disputed by the respondent(s)?
Schedule form 1: substituted, on 19 May 2011, by rule 8(a) of the Disputes Tribunals Amendment Rules 2011 (SR 2011/104).
What is this form for?
Use this form to extend the financial limit of your Disputes Tribunal claim. Complete this agreement only if your claim is for more than $15,000 but is not for more than $20,000. The Tribunal can only hear and determine claims within that range if all parties agree to the Tribunal being authorised to do that, and sign and date this form.
Completing and submitting this form
Part 1: Applicant's claim and parties to it
Applicant's claim: [reference number or brief description of claim]
Applicant's name (individual or organisation):
Attention (organisation's contact):
First respondent's name (individual or organisation):
Attention (organisation's contact):
Name of second respondent (if any, individual or organisation):
Attention (organisation's contact):
Applicant's insurer's full legal name (if a party under section 28(4) or (5) or 29(3)(b) of the Act):
Attention (insurer's contact):
Respondent's insurer's full legal name (if a party under section 35(6) of the Act):
Attention (insurer's contact):
Part 2: Agreement
We agree to extend the financial limit of the applicant's claim to (maximum $20,000): $[amount]
Applicant’s signature:
Date:
First respondent’s signature:
Date:
Second respondent’s signature:
Date:
Applicant's insurer’s signature:
Date:
Schedule form 1A: inserted, on 19 May 2011, by rule 8(b) of the Disputes Tribunals Amendment Rules 2011 (SR 2011/104).
What is this form for?
Use this form if you (the applicant) have been, are entitled to be, or have sought to be, indemnified (that is, compensated) by your insurer for any loss caused by or arising out of the act, omission, or event on which your Disputes Tribunal claim is based, and your insurer wishes to waive notice of proceedings, or to abandon rights of subrogation, or both, in respect of your Disputes Tribunal claim.
Completing and submitting this form
What is subrogation?
Subrogation is an insurer taking the place of an insured person, and having the benefit of the insured person’s rights, in respect of the insured person’s claim against a third person.
Part 1: Parties and insurers
Applicant's name (individual or organisation):
Attention (organisation's contact):
First respondent's name (individual or organisation):
Attention (organisation's contact):
Name of second respondent (if any, individual or organisation):
Attention (organisation's contact):
Applicant's insurer's full legal name:
Attention (insurer's contact):
Part 2: Waiver of notice of proceedings
Does the applicant's insurer require notice? Yes / No
Part 3: Subrogation
Select and complete the options that apply.
There are no uninsured losses.
or
There are uninsured losses of the following amount, namely: $[amount]
The insured losses are of the following amount, namely: $[amount]
The applicant's insurer abandons subrogation rights in respect of $[amount] and wishes to exercise subrogation rights in respect of the balance of the insured losses of $[amount].
or
The applicant's insurer abandons all subrogation rights.
Part 4: Applicant's insurer's details
Insurance claim number:
Applicant's insurer's full legal name:
Attention (insurer's contact):
Contact details
Daytime telephone number:
Mobile telephone number:
Fax number:
Email address:
Insurer’s signature:
Date:
Applicant’s signature:
Date:
Schedule form 4: substituted, on 19 May 2011, by rule 8(a) of the Disputes Tribunals Amendment Rules 2011 (SR 2011/104).
What is this form for?
Use this form to object to an application made to a District Court for the issue of any process to enforce an order—
Completing and submitting this form
Part 1: Party (individual or organisation) objecting to enforcement of order
Individual's family name(s):
Individual's first name(s):
Organisation's name (if a corporation or unincorporated body of persons, for example, an individual's employer):
Attention (organisation's contact):
Physical address (a physical address is required)
Street or road (number and name):
Rural delivery number:
Suburb:
City, town, or district:
Postcode:
Postal address (if different from physical address)
Street or road (number and name):
Rural delivery number:
Suburb:
City, town, or district:
Postcode:
Contact details
Daytime telephone number:
Mobile telephone number:
Email address:
Part 2: First party (individual or organisation) seeking enforcement of order
Individual's family name(s):
Individual's first name(s):
Organisation's name (if a corporation or unincorporated body of persons, for example, an individual's employer):
Attention (organisation's contact):
Physical address (a physical address is required)
Street or road (number and name):
Rural delivery number:
Suburb:
City, town, or district:
Postcode:
Postal address (if different from physical address)
Street or road (number and name):
Rural delivery number:
Suburb:
City, town, or district:
Postcode:
Contact details
Daytime telephone number:
Mobile telephone number:
Email address:
Part 3: Second party (another individual or organisation, if any) seeking enforcement of order
Individual's family name(s):
Individual's first name(s):
Organisation's name (if a corporation or unincorporated body of persons, for example, an individual's employer):
Attention (organisation's contact):
Physical address (a physical address is required)
Street or road (number and name):
Rural delivery number:
Suburb:
City, town, or district:
Postcode:
Postal address (if different from physical address)
Street or road (number and name):
Rural delivery number:
Suburb:
City, town, or district:
Postcode:
Contact details
Daytime telephone number:
Mobile telephone number:
Email address:
Part 4: Decision
Date of Tribunal decision:
Place of hearing (that is, name of the District Court where the Disputes Tribunal hearing was held):
CIV number (as stated on the Tribunal's decision):
Part 5: Declaration
I, the objector, believe the order was fully complied with on or before: [date].
Schedule form 6: substituted, on 19 May 2011, by rule 8(a) of the Disputes Tribunals Amendment Rules 2011 (SR 2011/104).
What is this form for?
Use this form to make a request for the enforcement of a work order.
Completing and submitting this form
Part 1: Applicant (individual or organisation)
Individual's family name(s):
Individual's first name(s):
Organisation's name (if a corporation or unincorporated body of persons, for example, an individual's employer):
Attention (organisation's contact):
Physical address (a physical address is required)
Street or road (number and name):
Rural delivery number:
Suburb:
City, town, or district:
Postcode:
Postal address (if different from physical address)
Street or road (number and name):
Rural delivery number:
Suburb:
City, town, or district:
Postcode:
Contact details
Daytime telephone number:
Mobile telephone number:
Email address:
Part 2: First respondent (individual or organisation)
Individual's family name(s):
Individual's first name(s):
Organisation's name (if a corporation or unincorporated body of persons, for example, an individual's employer):
Attention (organisation's contact):
Physical address (a physical address is required)
Street or road (number and name):
Rural delivery number:
Suburb:
City, town, or district:
Postcode:
Postal address (if different from physical address)
Street or road (number and name):
Rural delivery number:
Suburb:
City, town, or district:
Postcode:
Contact details
Daytime telephone number:
Mobile telephone number:
Email address:
Part 3: Second respondent (if any, individual or organisation)
Individual's family name(s):
Individual's first name(s):
Organisation's name (if a corporation or unincorporated body of persons, for example, an individual's employer):
Attention (organisation's contact):
Physical address (a physical address is required)
Street or road (number and name):
Rural delivery number:
Suburb:
City, town, or district:
Postcode:
Postal address (if different from physical address)
Street or road (number and name):
Rural delivery number:
Suburb:
City, town, or district:
Postcode:
Contact details
Daytime telephone number:
Mobile telephone number:
Email address:
Part 4: Decision
Date of Tribunal decision:
Place of hearing (that is, name of the District Court where the Disputes Tribunal hearing was held):
CIV number (as stated on the Tribunal's decision):
Part 5: Request
State the following information:
the term(s) of the order you want enforced:
the reasons why you consider the order has not been complied with:
whether the other party has complied with the alternative money order:
all other relevant information (if any).
Schedule form 7: substituted, on 19 May 2011, by rule 8(a) of the Disputes Tribunals Amendment Rules 2011 (SR 2011/104).
What is this form for?
Use this form if you wish to have enforced a term of an agreed settlement that has not been complied with.
Completing and submitting this form
Part 1: Applicant (individual or organisation)
Individual's family name(s):
Individual's first name(s):
Organisation's name (if a corporation or unincorporated body of persons, for example, an individual's employer):
Attention (organisation's contact):
Physical address (a physical address is required)
Street or road (number and name):
Rural delivery number:
Suburb:
City, town, or district:
Postcode:
Postal address (if different from physical address)
Street or road (number and name):
Rural delivery number:
Suburb:
City, town, or district:
Postcode:
Contact details
Daytime telephone number:
Mobile telephone number:
Email address:
Part 2: First respondent (individual or organisation)
Individual's family name(s):
Individual's first name(s):
Organisation's name (if a corporation or unincorporated body of persons, for example, an individual's employer):
Attention (organisation's contact):
Physical address (a physical address is required)
Street or road (number and name):
Rural delivery number:
Suburb:
City, town, or district:
Postcode:
Postal address (if different from physical address)
Street or road (number and name):
Rural delivery number:
Suburb:
City, town, or district:
Postcode:
Contact details
Daytime telephone number:
Mobile telephone number:
Email address:
Part 3: Second respondent (if any, individual or organisation)
Individual's family name(s):
Individual's first name(s):
Organisation's name (if a corporation or unincorporated body of persons, for example, an individual's employer):
Attention (organisation's contact):
Physical address (a physical address is required)
Street or road (number and name):
Rural delivery number:
Suburb:
City, town, or district:
Postcode:
Postal address (if different from physical address)
Street or road (number and name):
Rural delivery number:
Suburb:
City, town, or district:
Postcode:
Contact details
Daytime telephone number:
Mobile telephone number:
Email address:
Part 4: Decision
Date of Tribunal decision:
Place of hearing (that is, name of the District Court where the Disputes Tribunal hearing was held):
CIV number (as stated on the Tribunal's decision):
Part 5: Request
State the term you want enforced, the reasons why you consider the term has not been complied with, and any other relevant information.
Schedule form 8: substituted, on 19 May 2011, by rule 8(a) of the Disputes Tribunals Amendment Rules 2011 (SR 2011/104).
What is this form for?
Use this form to apply for a rehearing of your dispute. An application for rehearing can only be made after a Disputes Tribunal order (or approval of agreed settlement or variation of term of agreed settlement). You should provide reasons and evidence to support your application.
Completing and submitting this form
3 This application must be filed within 28 days of the Disputes Tribunal order (or approval of agreed settlement or variation of term of agreed settlement). If an order made by the Tribunal requires you to make a payment within that 28-day period for filing, you should file this application as early as possible before or after the order requires you to make that payment.
4 If you are filing after that 28-day period for filing, you will need to write to the Disputes Tribunal seeking permission for your application to be considered, and explaining your reason for filing late.
What happens after you have submitted this form
Filing this application does not affect any enforcement action. You can, however, apply to the District Court (but a filing fee is payable for an application) for a stay of proceedings.
Part 1: Applicant (individual or organisation)
Individual's family name(s):
Individual's first name(s):
Organisation's name (if a corporation or unincorporated body of persons, for example, an individual's employer):
Attention (organisation's contact):
Physical address (a physical address is required)
Street or road (number and name):
Rural delivery number:
Suburb:
City, town, or district:
Postcode:
Postal address (if different from physical address)
Street or road (number and name):
Rural delivery number:
Suburb:
City, town, or district:
Postcode:
Contact details
Daytime telephone number:
Mobile telephone number:
Email address:
Part 2: First respondent (individual or organisation)
Individual's family name(s):
Individual's first name(s):
Organisation's name (if a corporation or unincorporated body of persons, for example, an individual's employer):
Attention (organisation's contact):
Physical address (a physical address is required)
Street or road (number and name):
Rural delivery number:
Suburb:
City, town, or district:
Postcode:
Postal address (if different from physical address)
Street or road (number and name):
Rural delivery number:
Suburb:
City, town, or district:
Postcode:
Contact details
Daytime telephone number:
Mobile telephone number:
Email address:
Part 3: Second respondent (if any, individual or organisation)
Individual's family name(s):
Individual's first name(s):
Organisation's name (if a corporation or unincorporated body of persons, for example, an individual's employer):
Attention (organisation's contact):
Physical address (a physical address is required)
Street or road (number and name):
Rural delivery number:
Suburb:
City, town, or district:
Postcode:
Postal address (if different from physical address)
Street or road (number and name):
Rural delivery number:
Suburb:
City, town, or district:
Postcode:
Contact details
Daytime telephone number:
Mobile telephone number:
Email address:
Part 4: Grounds
State the reasons you are applying for a rehearing.
Part 5: Decision
Date of Tribunal decision:
Place of hearing (that is, name of the District Court where the Disputes Tribunal hearing was held):
CIV number (as stated on the Tribunal's decision):
Schedule form 9: substituted, on 19 May 2011, by rule 8(b) of the Disputes Tribunals Amendment Rules 2011 (SR 2011/104).
What is this form for?
Use this form to appeal to a District Court against a decision of the Disputes Tribunal.
Completing and submitting this form
5 If you are filing after that 28-day period for filing, you should do so only within any further time for filing that you have sought by an application made to, and have been allowed by, a District Court Judge.
Part 1: Appellant (you, the individual or organisation appealing against the Tribunal's decision)
Individual's family name(s):
Individual's first name(s):
Organisation's name (if a corporation or unincorporated body of persons, for example, an individual's employer):
Attention (organisation's contact):
Physical address (a physical address is required)
Street or road (number and name):
Rural delivery number:
Suburb:
City, town, or district:
Postcode:
Postal address (if different from physical address)
Street or road (number and name):
Rural delivery number:
Suburb:
City, town, or district:
Postcode:
Contact details
Daytime telephone number:
Mobile telephone number:
Email address:
Part 2: First respondent (individual or organisation)
Individual's family name(s):
Individual's first name(s):
Organisation's name (if a corporation or unincorporated body of persons, for example, an individual's employer):
Attention (organisation's contact):
Physical address (a physical address is required)
Street or road (number and name):
Rural delivery number:
Suburb:
City, town, or district:
Postcode:
Postal address (if different from physical address)
Street or road (number and name):
Rural delivery number:
Suburb:
City, town, or district:
Postcode:
Contact details
Daytime telephone number:
Mobile telephone number:
Email address:
Part 3: Second respondent (if any, individual or organisation)
Individual's family name(s):
Individual's first name(s):
Organisation's name (if a corporation or unincorporated body of persons, for example, an individual's employer):
Attention (organisation's contact):
Physical address (a physical address is required)
Street or road (number and name):
Rural delivery number:
Suburb:
City, town, or district:
Postcode:
Postal address (if different from physical address)
Street or road (number and name):
Rural delivery number:
Suburb:
City, town, or district:
Postcode:
Contact details
Daytime telephone number:
Mobile telephone number:
Email address:
Part 4: Appellant's insurer (if any)
If your insurer was a party to the claim (under section 28(4) or (5), 29(3)(b), or 35(6) of the Act), complete the following:
Your insurer's full legal name:
Your insurance claim number:
Your insurer’s postal address:
Part 5: Decision
Date of Tribunal decision:
Place of hearing (that is, name of the District Court where the Disputes Tribunal hearing was held):
CIV number (as stated on the Tribunal's decision):
Part 6: Appeal
What are you appealing against?
State what was—
Forms submitted by (select the option that applies):
Appellant:
or
Appellant’s lawyer:
Signature:
Date:
Schedule form 10: substituted, on 19 May 2011, by rule 8(a) of the Disputes Tribunals Amendment Rules 2011 (SR 2011/104).