Mediation Services

Applicant & Respondent > Application Details > Supporting Documents > Declaration

>  Applicant & Respondent
  Application Details
  Supporting Documents
  Declaration

Application Type

Applicant Details

Please enter details as per the lease or agreement

Applicant Type

Business Name

ABN

ACN

First Name

Last Name

Contact Number

Email Address

Do you require an interpreter? If yes what language?

YesNo

Language

Street Address

Unable to find address?

Street Address

City

Postcode

State

Returned-Data-0

streetNameLong

localityName

stateTerritory

postcode

addressId

lgaName

stateElectoralName

geoLongitude

geoLatitude

Does the applicant have a representative?

YesNo

Representative for Applicant

Role

Business Name

ABN

ACN

First Name

Last Name

Phone Number

Email Address

Street Address

Unable to find address?

Street Address

City

Postcode

State

Returned-Data-1

streetNameLong

localityName

stateTerritory

postcode

addressId

lgaName

stateElectoralName

geoLongitude

geoLatitude

This is the best person to discuss the application

Would you like to add another representative

YesNo

Second Representative for Applicant

Role

Business Name

ABN

ACN

First Name

Last Name

Phone Number

Email Address

Street Address

Unable to find address?

Street Address

City

Postcode

State

Returned-Data-2

streetNameLong

localityName

stateTerritory

postcode

addressId

lgaName

stateElectoralName

geoLongitude

geoLatitude

This is the best person to discuss the application

Mediation Services

Applicant & Respondent > Application Details > Supporting Documents > Declaration

>  Applicant & Respondent
  Application Details
  Supporting Documents
  Declaration

Shop Details

Street Address

Suburb

Postcode

Type of Premises?

Shopping Centre Name (if applicable)

Permitted use on lease

When did the lease start (if known)

Lease security type

Other Security (please specify)

Shop Size

Please attach any plans in the supporting documents section

Bond number (if known)

Bond amount (if known)

Current annual rent

Dispute Details

NB All details provided on this application form will be provided to the respondent(s)

What issues would you like to raise at mediation?

What do you hope to achieve from mediation? How would you like the dispute to be resolved?

Has the Lessee been locked out?

YesNo

Total amount of claim if applicable

Valuation

Are the Parties unable to agree on the current market rent?

YesNo

Are the Parties unable to agree on the appointment of a SRV?

YesNo

If you have not tried to seek an agreement on the current market rent or appointment of a SRV, please try before proceeding with this application

Does your lease require a current market rent review or provide an option to renew or extend your lease at current market rent?

YesNo

If you are seeking a current market rent review for another reason, please provide details:

From what date should the reviewed rent begin? (it can be prior to the valuation process)

Do you have any other comments?

Determination

Name of SRV who completed the original determination

When did you receive the copy of the original determination?

The application for review must be made within 21 days after receiving the original determination

Mediation Services

Applicant & Respondent > Application Details > Supporting Documents > Declaration

>  Applicant & Respondent
  Application Details
  Supporting Documents
  Declaration

Supporting Documents Upload

Please note: The total size for lease and supporting document must not exceed 30 megabytes (MB).

Further documents can be provided after the application is assigned to a Mediation Officer as only ONE file per upload.

A copy of the lease

A copy of the original determination

Any additional information about your application

Mediation Services

Applicant & Respondent > Application Details > Supporting Documents > Declaration

>  Applicant & Respondent
  Application Details
  Supporting Documents
  Declaration

I hereby declare the following:

The information provided in this application form is true and accurate so far as I am aware;

I am legally authorised to sign this application for and on behalf of the applicant;

I undertake to pay my share of the costs of the mediator on the day of mediation, and;

I consent to my application and attached documents being provided to the other party and the mediator

under section 26(2) of the Privacy and Personal Information Protection Act 1998 (NSW).

I hereby declare the following:

The parties have been unable to reach an agreement on the appointment of an SRV

The information provided in this application form is true and accurate so far as I am aware;

I am legally authorised to sign this application for and on behalf of the applicant;

I consent to my application and attached documents being provided to the other side

and the SRV under section 26(2) of the Privacy and Personal Information Protection Act 1998 (NSW).

I hereby declare the following:

The information provided in this application form is true and accurate so far as I am aware;

I understand the requesting party is required to pay the full amount for the review if

the current market rent is jointly determined to be the same or within 10% of the

original determination;

I am legally authorised to sign this application for and on behalf of the party requesting

a review;

I consent to my application and attached documents being provided to the other party

and the SRVs under section 26(2) of the Privacy and Personal Information Protection Act 1998 (NSW).

I hereby accept the declaration

First Name

Last Name

Position / Authority

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