Request to Provide an Adjudication Certificate

REQUEST TO THE INSTITUTE OF ARBITRATORS AND MEDIATORS AUSTRALIA (IAMA) TO PROVIDE AN ADJUDICATION CERTIFICATE

NOTE:The Building and Construction Industry Payments Act 2004 (QLD) (the Act) provides at Section 30 that if a respondent fails to pay the whole or any part of the adjudicated amount to the claimant in accordance with section 29 of the Act, the claimant may request the authorised nominating authority to whom the adjudication application was made to provide an adjudication certificate under this section.

The Act at Section 29(2) provides that the relevant date for the purpose of Section 29 means:

a)the date occurring 5 business days after the date on which the adjudicator’s determination is served on the respondent concerned, or

b)if the adjudicator determines a later date under Section 26(1)(b) – that later date.

The Act at Section 29(1) provides that if an adjudicator determines that a respondent is required to pay an adjudicated amount, the respondent must pay that amount to the claimant on or before the relevant date.

The Institute’s fee for the issuing of an Adjudication Certificate is $275.00 (including GST). Payment must accompany this request form.

THIS FORM BECOMES A TAX INVOICE/TAX RECEIPT ON FULL PAYMENT

ABN NO. 80 008 520 045

Payment Options:

Please find enclosed payment of $275.00 (inclusive of GST)

 Cheque (made payable to Institute of Arbitrators & Mediators, Australia)

 Direct Debit/Electronic Funds Transfer:

Account Name:Institute of Arbitrators & Mediators, Australia

Bank and Branch:National Australia Bank, 330 Collins Street, Melbourne

BSB Number:083 016

Account Number:682975533

 Credit Card (complete details below)

 Bankcard  Mastercard  Visa

Cardholder’s Name:

Card Number: Expiry Date:

Cardholder’s Signature:

This a request to provide an Adjudication Certificate pursuant to Section 30 of the Building and Construction Industry Payments Act 2004 (QLD) (the Act).

Authorised Nominating Authority (ANA) to whom the Adjudication Application was made: / Institute of Arbitrators and Mediators Australia Level 23, 127 Creek Street, Brisbane
Adjudication Application Matter Number: / Matter No. ………..
Claimant’s Name:
Address / …………………………………………..
………………………………………………………………………………………………………………………………
Name of respondent who is liable to pay the claimant the adjudicated amount:
Address /

…………………………………

………………………………………………………………………………………………………………………………
Name of adjudicator: /

……………………………..

Date of adjudication decision: / …………………………
Adjudicated amount determined by the adjudicator: / $
Date on which payment of the adjudicated amount is payable: / ………………………….
Rate of interest payable on the adjudicated amount determined by the adjudicator is: / %
The unpaid share of the adjudicator’s fees is: / $

Name of person making this declaration:……….…………………………………………

Address of person making this declaration: ……….…………………………………………

Relationship to or position with the Claimant:……….…………………………………………

Contact details: Telephone: ………………………… Facsimile: ………………………..

I declare that the information provided by me in this request is true and correct and that I have the authority of the Claimant to make this declaration and request. I understand that this declaration is not the affidavit referred to in Section 31(2) of the Act.

Signature: ………………………………………………… Date: ………………….