IN THE FEDERAL CIRCUIT AND				File number: ................................
FAMILY COURT OF AUSTRALIA
REGISTRY: ........................................................
......................................................................
Applicant
.....................................................................
Respondent
Repeat as necessary for additional parties
Form 4
Fair Work Division
Rule 30.06(b)	Claim under the Fair Work Act 2009 alleging contravention of a general protection
Is discrimination contrary to s.351 of the Fair Work Act alleged? 
(see Q 19 below) 	Yes 		No 	

Part A – Details of person affected by the contravention	
1. Name	If an individual:
Mr 	Mrs 	Ms 
Other   (give details):  ……………………………….
Family name:	.....................................................................
Given names:	.....................................................................
If a company:
Name and ABN:  ..............................................................................	
2. Address or registered office	...........................................................................................................
..............................................................................Postcode:	.........	
3. Phone	Business hours:	(.....) ...............................
After hours:		(.....) ...............................
Mobile:			.........................................	
4. First language 
(if an individual)		English
	Other (specify):...........................................................	

Part B – Details of respondent (repeat as necessary for additional parties)	
5. Name	     	
6. Address or registered office	..........................................................................................................
....................................................................Postcode: ...................
Phone:	(.....) ...............................
Fax:	(.....) ............................... 	

Part C – If the applicant is an individual or company – details of representation	
7. Is an organisation, such as a union, acting on your behalf?		No - go to 14
	Yes - go to 8	
8. Name of organisation	     	
9. Address	..........................................................................................................
....................................................................Postcode: ...................	
10. Contact person 	Name:	...............................................................................................
Phone:	(.....) ...............................
Fax:	(.....) ............................... 	

Part D – If the applicant is an industrial association – details of representation	
11. Is a member, officer or employee of the applicant representing it?		No - go to 14
	Yes - go to 12	
12. Name of the member, officer or employee	     	
13. Address	...........................................................................................................
..............................................................................Postcode:.............
DX:	...............................
Phone:	(.....) ...............................
Fax:	(.....) ...............................	

Part E – Details of lawyer	
14. Is a lawyer representing you?		No - go to 18
	Yes - go to 15	
15. Lawyer’s name	     	
16. Name of lawyer’s firm	     	
17. Address	.....................................................................................................................
..............................................................................Postcode:...................
DX:	........................................
Phone:	(.....) ...............................
Fax:	(.....) ...............................	

Part F – Notices from the Court	
18. Where do you want notices from the Court sent?		address in 2
	organisation in 8‑10
	address in 12-13
	lawyer in 15-17
	other (give details):	.........................................................	
Part G – Contravention(s) alleged	
19. What are the grounds for the claim that adverse action against the applicant has been taken, threatened or organised contrary to the Fair Work Act?
(Set out in numbered paragraphs the facts 
relied on and the provisions of the Fair Work Act relevant to the claim)
1.	Specify the ‘adverse action’
2.	If relying on s.340 specify the workplace right
3.	If relying on s.351 specify the attribute in s.351(1)
Attach an extra sheet if required	     	

Part H – Details of work or services (where relevant)	
20. Work or services performed or to be performed by employee or independent contractor	     	
21. Place of work or services	.....................................................................................................................
..............................................................................Postcode:	...................

Part I – Remedy sought	
22. What are you asking the Court for?		Injunction
	Please specify on an attached sheet the terms of the injunction or injunctions sought.
	Compensation
	Please give details on an attached sheet of how much compensation the employee is claiming and how the amount has been calculated (eg loss of income).
	Reinstatement
	Pecuniary penalty
	Other
	Please give details on an attached sheet	
23. To whom should any compensation, pecuniary penalty or other amount ordered be paid?		Compensation:  ........................................
	Pecuniary penalty:  ........................................
	Other:  ........................................

Signature of applicant, lawyer or authorised representative
	
Signed by (print name) ....................................................
	the applicant
	lawyer for the applicant
	authorised representative of the applicant
Date:	............/............/...........	

Form approved by the Chief Judge pursuant to subrule 2.04(1) for the purpose of subrule 30.06(b)
FW_ClaimForm4_0921V1