Completing this form
• Print clearly in CAPITALS
• Use a black pen or blue pen to complete
• Answer every question on the form unless
the instructions tell you otherwise
The fee for filing an appeal is $200.
You can pay the fee in person when you are
handing your application in over the counter.
Other costs can be incurred going through this
The only grounds for an appeal are that the
manner in which the Referee conducted the
hearing (for example, because the Referee failed
to have regards to a provision of an enactment
brought to the Referee’s attention) or the manner
in which the investigator carried out the
• unfair to you; and
• prejudicially affected the results of the
This notice of appeal must be filed within 20
working days of the Disputes Tribunal’s order (or
approval of agreed settlement or variation of term
of agreed settlement).
If you are filing after that 20 working day period
for filing, you should do so only within any further
time for filing that you have sought by an
application made to, and have been allowed by, a
District Court Judge.
More information can be found at
When to use this form
Use this form to appeal to a District Court against a decision of the Disputes Tribunal.
What you need with your application
To complete your appeal, you need to send:
• A fully completed form
• The filing fee of $200 (Please read the payment information)
• Attached any relevant evidence to support your appeal