IN THE FEDERAL CIRCUIT AND		File number: ...........................................
FAMILY COURT OF AUSTRALIA
REGISTRY: ........................................................
......................................................................
Applicant
.....................................................................
Respondent
Repeat as necessary for additional parties
Form 5
Fair Work Division
Rule 30.11(b)
	Small claim under the Fair Work Act 2009	

Part A – Details of employee or outworker	
1. Name	Mr 	Mrs 	Ms 
Other   (give details):  .....................................................
Family name:	.....................................................................
Given names:	.....................................................................	
2. Address	......................................................................................................................................................................................Postcode:................	
3. Phone	Business hours:	(.....) ...............................
After hours:	(.....) ...............................
Mobile:	.........................................	
4. Date of birth	............/............/...........	
5. First language		English
	Other (specify):	.....................................................................
Does the applicant require an interpreter?
No 	Yes 
If Yes, what language:  ...............................................................	

Part B – Details of employer or outworker entity	
6. Name of employer or outworker entity	     	
7. Address or registered office	........................................................................................................................................................................................Postcode:..............
Phone:	(.....) ...............................
Fax:	(.....) ............................... 	

Part C – If the applicant is an individual – details of representation	
8. Is an organisation such as a union, acting on your behalf?		No - go to 15
	Yes - go to 9	
9. Name of organisation	     	
10. Address	...................................................................................................................................................................................Postcode:...................	
11. Contact person 	Name:.................................................................................................
Phone:	(.....) ...............................
Fax:	(.....) ............................... 	

Part D – If the applicant is an industrial association – details of representation	
12. Is a member, officer or employee of the applicant representing it?		No - go to 15
	Yes - go to 13	
13. Name of the member, officer or employee	     	
14. Address	...................................................................................................................................................................................Postcode:...................
Phone:	(.....) ...............................
Fax:	(.....) ...............................	

Part E – Notices from the Court	
15. Where do you want notices from the Court sent?		address in 2
	organisation in 9-11
	address in 13‑14
	other (give details):....................................................................	

Part F – Details of work performed by employee or outworker	
16. Occupation	     	
17. Work or services performed	     	
18. Duties
A brief summary of the employee or outworker’s duties	     	
19. Classification level under applicable Modern Award, enterprise agreement, workplace determination or contract	     	
20. Place of work or services	.....................................................................................................................
..............................................................................Postcode:	...................	
21. Period of employment or outworker contract	Date started work:	............/............/...........
Last date worked:	............/............/........... 
if employment or outworker arrangement terminated	
22. If the employee’s employment or the outworker’s contract was terminated, was a written notice of dismissal or termination given?		No
	Yes -  copy attached
	
23. Employment status	 full-time 
 part time
 casual
 fixed term
 seasonal
 outworker	
24. Hours of work	Did the employee or outworker work regular hours?
 Yes
 No
If Yes, complete the following: 
Day	
Start time
(state am or pm)	
Finish time
(state am or pm)	

Monday	
     	
     	

Tuesday	
     	
     	

Wednesday	
     	
     	

Thursday	
     	
     	

Friday	
     	
     	

Saturday	
     	
     	

Sunday	
     	
     	

		

Part G – Contravention alleged	
25. The applicant alleges that the employer or outworker entity has breached:
select one or more as appropriate)	 one of the National Employment Standards 
Please specify the standard:
..............................................................................	
	 a term of a Modern Award 
Please specify the Modern Award and the relevant term:
..............................................................................	
	 an enterprise agreement
Please specify the enterprise agreement and the relevant term:
..............................................................................	
	 a workplace determination
Please specify the determination and the relevant provision:
..............................................................................	
	 a national minimum wage order 
Please specify:
..............................................................................	
	 an equal remuneration order
Please specify:
..............................................................................	
	 a safety net contractual entitlement 
Please specify:
..............................................................................
 other
Please specify: ..............................................................................	

Part H – Remedy sought	
26. Tick the box for each sort of claim you are making and insert the amount claimed
		
	 wages	$     	
	 overtime rate	$     	
	 penalty rate	$     	
	 allowances	$     	
	 leave		
	 annual	$     	
	 personal/carer’s	$     	
	 compassionate	$     	
	 jury service	$     	
	 other (please identify): 
...............................	$     	
	 public holiday	$     	
	 redundancy pay	$     	
	 superannuation claim	$     
	
	Total	$     	
27. To whom should any compensation be paid?	     	
Part I – details of claim	
Describe the basis for the claim for each of the boxes ticked in Question 26 and the method of calculation of the amount claimed.
Attach an extra sheet if required	     	

Signature of applicant or authorised representative
	
Signed by (print name) ....................................................
	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 30.11(b)
FW_ClaimForm5_0921V1