DT NOTICE OF APPEAL TO DISTRICT COURT 31/10/2019
Notice of appeal to District Court
DISPUTES TRIBUNAL
Completing this form
Print clearly in CAPITALS
Use a black pen or blue pen to complete
this form
Answer every question on the form unless
the instructions tell you otherwise
Payment information
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
process.
Important information
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
investigation was:
unfair to you; and
prejudicially affected the results of the
proceedings.
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
disputestribunal.govt.nz/
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
Rule 24, Disputes Tribunal Rules 1989
DT NOTICE OF APPEAL TO DISTRICT COURT 31/10/2019
Step 1. Appellants details
Are you an individual or organisation? (Please tick ONE to confirm)
Individual
Organisation
If you are an Individual provide the full name below. Individual includes each trustee of a Trust (name all
trustees) or if the individual is trading but not under a registered company.
Full name
If you are an Organisation provide the full legal name and contact person below. Organisation includes an
incorporated company or other incorporated entity (for example - an incorporated society/charitable trust).
Full legal name
Contact person
What is the physical address?
Address
What is the postal address? (if different from the physical address)
Address
Phone
Day
Mobile
Email
Step 2. Appellants insurance and insurer details
If your insurer was party to the claim (under section 28(4) or (5), 26(3)(b), or 35(6) of the Act), complete the
following:
Insurers full legal name
Insurance claim number
What is their postal address?
Address
DT NOTICE OF APPEAL TO DISTRICT COURT 31/10/19
Step 3. First respondent details
Are they an individual or organisation? (Please tick ONE to confirm)
Individual
Organisation
If they are an Individual provide the full name below. Individual includes each trustee of a Trust (name all
trustees) or if the individual is trading but not under a registered company.
Full name
If they are an Organisation provide the full legal name and contact person below. Organisation includes an
incorporated company or other incorporated entity (for example - an incorporated society/charitable trust).
Full legal name
Contact person
What is their postal address?
Address
Phone
Day
Mobile
Email
Step 4. Second respondent details
Are they an individual or organisation? (Please tick ONE to confirm)
Individual
Organisation
If they are an Individual provide the full name below. Individual includes each trustee of a Trust (name all
trustees) or if the individual is trading but not under a registered company.
Full name
If they are an Organisation provide the full legal name and contact person below. Organisation includes an
incorporated company or other incorporated entity (for example - an incorporated society/charitable trust).
Full legal name
Contact person
What is their postal address?
Address
Phone
Day
Mobile
Email
Note: If you need extra space for additional respondents, please attach a separate sheet with their information to
this application
DT NOTICE OF APPEAL TO DISTRICT COURT 31/10/19
Step 5. Decision details
Date of the decision
/
/
(day/month/year)
Place of hearing
CIV number
Step 6. Appeal
Please state what was unfair to you and prejudicially affected your claim.
If you need extra space, please attach a separate sheet to this application
Step 7 Sign and date this form
Appellant signature
Date
Step 8. Send in this form
You can fill in this form and hand it in at your local court.
Address: find your local court address at justice.govt.nz/contact-us/find-us/
Phone: 0800 268 787
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