IN THE FEDERAL CIRCUIT AND	File number: ....................................
FAMILY COURT OF AUSTRALIA
REGISTRY: ........................................................
......................................................................
Applicant
.....................................................................
Respondent
Repeat as necessary for additional parties
Form 6
Fair Work Division
Rule 30.08	Claim under the Fair Work (Registered Organisations) Act 2009 alleging reprisal

Part A – Details of the applicant	
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 11
	Yes - go to 8	
8. Name of organisation	     	
9. Address	.............................................................................................................................................................................................Postcode:.........	
10. Contact person 	Name:.................................................................................................
Phone:	(.....) ...............................
Fax:	(.....) ............................... 	

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

Part E – Notices from the Court	
15. Where do you want notices from the Court sent?		address in 2
	organisation in 8‑10
	lawyer in 12-14
	other (give details):....................................................................	

Part F – Conduct alleged	
16. What are the grounds for the claim that a reprisal
(a) is being taken against the applicant
(b) is being threatened against the applicant
(c) has been taken against the applicant
or
(d) has been threatened against the applicant?

(Set out in numbered paragraphs the facts relied on)
Attach an extra sheet if required	     

Part G– Involvement of accessory	
17. Is the applicant making a claim against one or more additional persons on the basis that they were also involved in the conduct set out in the answer to question 16?		No - go to 21
	Yes - go to 18
	
18. Please identify each of those persons.		
19 In respect of each of the persons identified in answer to question 18, please identify the basis on which it is alleged that the person was involved in the conduct set out in the answer to question 16.	Name of person:
	Aided, abetted, counselled or procured the conduct
	Induced the conduct.
	Failed to fulfil a duty to prevent, refrain from, or take reasonable steps to ensure other persons under the person’s control prevented or refrained from, the conduct.
	Was knowingly concerned in or a party to the conduct.
	Conspired with others to effect the conduct.
Name of person:
	Aided, abetted, counselled or procured the conduct
	Induced the conduct.
	Failed to fulfil a duty to prevent, refrain from, or take reasonable steps to ensure other persons under the person’s control prevented or refrained from, the conduct.
	Was knowingly concerned in or a party to the conduct.
	Conspired with others to effect the conduct.
Name of person:
	Aided, abetted, counselled or procured the conduct
	Induced the conduct.
	Failed to fulfil a duty to prevent, refrain from, or take reasonable steps to ensure other persons under the person’s control prevented or refrained from, the conduct.
	Was knowingly concerned in or a party to the conduct.
	Conspired with others to effect the conduct.	
20. In respect of each of the persons referred to in the answer(s) to question 19, what are the grounds for alleging that that person was involved, in the manner alleged, in the conduct set out in the answer to question 16?
(Set out in numbered paragraphs the facts relied on)
Attach an extra sheet if required		

Part H– Detriment alleged 	
21.  What detriment is it alleged the applicant has suffered?		Dismissal
	Injury in employment
	Discrimination between the applicant and other employees of the same employer;
	Harassment or intimidation
	Harm or injury, including psychological harm
	Damage to the applicant’s property
	Damage to the applicant’s reputation.	
22. What are the grounds for the claim that the applicant has suffered detriment?
(Set out in numbered paragraphs the facts relied on)
Attach an extra sheet if required		

Part I– Remedy sought	
23. 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 applicant is claiming and how the amount has been calculated (eg loss of income).
	Apology
Please specify on an attached sheet the terms of the apology sought.
	Reinstatement
	Exemplary damages
Please specify on an attached sheet why an order for exemplary damages would be appropriate in this case.
	Other
Please give details on an attached sheet
	
24. To whom should any compensation or other amount ordered be paid?		Compensation:  ........................................
	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 30.08(b)
FW_ClaimForm6_0921V1