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ADJUDICATION APPLICATION

I/we the Claimant make application under Section 17 of the Building and Construction Industry Security of Payment Act 2009, for the nomination of an adjudicator to determine a disputed payment claim.

CLAIMANT DETAILS
Company Name:
ABN/ACN:
Contact Name:
Address:
Phone No:
Facsimile No:
Email(s):
Claimant’s Representative
Company Name:
Contact Name:
Phone No:
Facsimile No:
Email(s):
RESPONDENT DETAILS
Company Name:
ABN/ACN:
Contact Name:
Address:
Phone No:
Facsimile No:
Email(s):
Respondent’s Representative (if known)
Company Name:
Contact Name:
Phone No:
Facsimile No:
Email(s):

CONTRACT / AGREEMENT DETAILS

  1. Written and/or Verbal:

  1. Project Site(s):

  1. Services contracted:

  1. Date Commenced:

  1. Contract Price or Rates:

PAYMENT CLAIM DETAILS

  1. Payment Claim No (if applicable):

  1. Date of Payment Claim:

  1. Date Payment Claim received by Respondent:

  1. Payment Claim amount: $

PAYMENT SCHEDULE in relation to PAYMENT CLAIM

  1. Received within 15 business days: Yes / No
(if No proceed to 14)
  1. Date of Payment Schedule:

  1. Date Payment Schedule received by Claimant:

  1. Payment Schedule amount: $

DUE DATE FOR PAYMENT
  1. In South Australia there are 2 possible due dates for payment:
(1) As per the written contract; OR if not specified
(2) A default under the legislation of 15 business days
  1. Based on 14 above, what is the due date for payment from the date the Respondent received the Payment Claim (see 8 above):

NOTICE OF INTENT TO APPLY FOR ADJUDICATION (s17(2) notice)
(only complete if there was no Payment Schedule at 11-14 above)
  1. Date of s17(2) notice:

  1. Date S17(2) received by Respondent:
(Note should be within 20 business days after the Due Date for Payment stated at 15 above)
  1. What is the fifth (5th) business day after the Respondent received the s17(2) notice:

PAYMENT SCHEDULE in relation to s17(2) Notice

(only complete if there was a s17(2) notice at 16-18 above)

  1. Received within 5 business days: Yes / No
(if No proceed to 23)
  1. Date of Payment Schedule:

  1. Date Payment Schedule received by Claimant:

  1. Payment Schedule amount: $

AMOUNT PAID (if applicable)

  1. Has any monies been paid since the Payment Claim received date (see 8 above): Yes / No

  1. If yes, itemise the payments and dates payment was received:

NOTES:

1.The Adjudication Application should be accompanied by the following:

Item / Tick
(a) / The Claimant’s submissions/story in support of their claim for payment. This may come as a statutory declaration
(b) / A copy of the contract under which the Claimant raised the Payment Claim
(c) / A copy of the Claimant’s Payment Claim and evidence the Payment Claim was served onto the Respondent
(d) / A copy of the Respondent’s Payment Schedule to the Payment Claim (if applicable)
(e) / A copy of the Claimant’s s17(2) notice (if applicable) and evidence the s19(2) notice was served onto the Respondent
(f) / A copy of the Respondent’s Payment Schedule to the s17(2) notice (if applicable)
(g) / All relevant submissions which the Claimant wants the Adjudicator to consider
(h) / Other relevant documents, for example, invoices from suppliers, measurements, test results, quality assurance certificates, statutory declarations, proof of insurance, experts reports, photos, emails, texts etc

!!! IMPORTANT !!!

A copy of the Adjudication Application is to be served on the Respondent at the same time or as soon as possible after it has been lodged. The Claimant is to notify ASC of the date of service on the Respondent and provide evidence of service.

Adjudication Fees

Declaration

In applying for adjudication the Claimant agrees that:

  • the information provided in this application is correct, and
  • The application form and its attachments have been read, is understood and is agreed; and
  • the Adjudication Terms and Conditions and fees applicable are agreed as listed in this application and as displayed on the website
  • The Claimant will provide evidence of the Claimant’s service of the adjudication application on the Respondent to the Adjudicator as soon as possible.

Claimant’s Signature / Printed Name / Date

Disclaimer
The use of this form is not mandatory. It is provided to assist a claimant make an adjudication application under the Act and the Adjudicator and the Respondent to see details easily. ASC takes no responsibility for any information provided by the Claimant in making an application under the Act. ASC disclaims any liability (including for negligence) to any person in respect of anything and the consequences of anything done or not done by any such person in reliance upon anything in or omitted from this adjudication application form. For parties to obtain a full appreciation of their rights and obligations it is recommended that they consult the Act or obtain legal advice.

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SA Adjudication Application Revision – April 2017

Regus Miranda Level 1, 29 Kiora Road Miranda NSW 2228 - Ph 1300 722 624 - Fax 1300 722 924

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