South Australian Employment Tribunal

Form A38 – Application – money claim

Form A38

Application for money claim under industrial law or instrument (Fair Work)

Case Number
(SAET use only)

About this form

·  This form is used for commencing proceedings in SAET to claim a monetary amount due under a State or Federal industrial law or agreement under section 9 of the Fair Work Act 1994 (SA).

·  For more information about money claims, please refer to www.saet.sa.gov.au.

·  Submitting an incomplete form (including any relevant supporting documents) may result in delays.

Summary of Application

Applicant Name
Role / ☐ an employee ☐ an employer ☐ other (specify):
Employed under / ☐ Fair Work Act 1994 (SA) / ☐ Fair Work Act 2009 (Cth) - do you elect for these proceedings to be dealt with as a small claim (under s548):
☐ Yes, small claim ☐ No
Respondent(s) Name

Party details

Applicant details

Organisation/ company name (if relevant)
Title / ☐ Mr ☐ Mrs ☐ Miss ☐ Ms ☐ Other (specify):
First name / Last name
Email
Telephone / Mobile
Address Street 1
Street 2
Suburb / State
Postcode / Country
Do you require an interpreter? / ☐ No ☐ Yes. Please specify language:
Do you have any special requirements which will require assistance? / ☐ No ☐ Yes. Please specify:
Is anyone representing you? / Note: If your proceedings are under the Fair Work Act 2009 (Cth) as a small claim, permission is required from SAET for you to be represented.
☐ No ☐ Yes. Please specify:

Applicant representative detail (if required)

Organisation
Contact First name / Last name
Email
Telephone / Mobile
Address Street 1
Street 2
Suburb / State
Postcode / Country

Employee details

Same details as applicant? / ☐ No – complete details ☐ Yes – skip to next section
Title / ☐ Mr ☐ Mrs ☐ Miss ☐ Ms ☐ Other (specify):
First name / Last name
Email
Telephone / Mobile
Address Street 1
Street 2
Suburb / State
Postcode / Country
Does the employee have any special requirements which will require assistance? / ☐ No ☐ Yes. Please specify:

Employer details

Same details as applicant? / ☐ No – complete details ☐ Yes – skip to next section
Employer’s name(s) / Registered
Trading name (if different)
Trading Address Street 1
Street 2
Suburb / State
Postcode / Country
Contact Title / ☐ Mr ☐ Mrs ☐ Miss ☐ Ms ☐ Other (specify):
First name / Last name
Email
Telephone / Mobile
Does the employer have any special requirements which will require assistance? / ☐ No ☐ Yes. Please specify:

Other legal proceedings

Are there other legal proceedings concerning the persons named on this claim? / ☐ No ☐ Yes. Please specify:

About the employment

Type of work performed by the employee for employer (occupation)?
Place of work (address)
Award or agreement covering employment
Classification
Type of employment (select all that apply) / ☐ Permanent
☐ Casual
☐ Full-time
☐ Part-time / ☐ Apprenticeship or traineeship
☐ Fixed term
☐ Seasonal
☐ Outworker
Period of employment / Commencement date:
Termination date (if applicable)
What is the period of to which this claim relates?

State act contraventions

If you are proceeding under the Fair Work Act 2009 (Cth) go to the next section.

State each section of the Fair Work Act 1994 (SA) that is relevant to this claim
What are you asking for? / ☐ Non-payment or underpayment of wages
☐ Overpayment of wages
☐ Long service leave
☐ Pre-judgment interest
☐ Other (specify):
To whom should any wages or other amount ordered be paid? / ☐ Wages – to be paid to:
☐ Other – to be paid to::

Commonwealth act contraventions

If you are not proceeding under the Fair Work Act 2009 (Cth) go to the next section.

State each section of the Fair Work Act 2009 (Cth) that is relevant to this claim
What are you asking for? / ☐ Non-payment or underpayment of wages
☐ Overpayment of wages
☐ Superannuation
☐ Long service leave
☐ Pecuniary penalty
☐ Pre-judgment interest
☐ Other (specify):
To whom should any wages or other amount ordered be paid? / ☐ Wages – to be paid to:
☐ Pecuniary penalty – to be paid to:
☐ Other – to be paid to::

Details of claim

Select the box for each sort of claim you are making and insert the amount claimed.
(How the amount claimed has been calculated should be set out on an attached sheet) /
Amount claimed
☐ Wages / $
☐ Overtime rate / $
☐ Penalty rate / $
☐ Allowances / $
☐ Commissions / $
☐ Redundancy pay / $
☐ Public holiday / $
☐ Payment in lieu of notice of termination of employment contract / $
☐ Superannuation (Cth) / $
☐ Leave
☐ Long service leave / $
☐ Annual / $
☐ Personal / Carer’s / $
☐ Compassionate / $
☐ Jury service / $
☐ Other (specify):
☐ / $
☐ / $
TOTAL AMOUNT / $

Reasons why you believe SAET should make an order for the amount claimed (attach more pages if required).

LODGING YOUR COMPLETED FORM

Name of person lodging
Signature
Date

Please lodge this form, together with any accompanying documents, with the South Australian Employment Tribunal:

Email:
Post: PO Box 3636, Rundle Mall, SA, 5000
In person: Level 6, Riverside Centre, North Terrace, Adelaide, 5000

PLEASE RETAIN A COPY OF THIS FORM FOR YOUR OWN RECORDS

www.saet.sa.gov.au

SAET Registry: 08 8207 0999