Form 2.1	Originating claim
Court Procedures Rules 2006
(see r 50 (Originating claim—content etc))
In the *[Supreme/Magistrates] Court of the Australian Capital Territory

No *[SC/MC]		of (year) (Court to complete)
*(if proceeding in Magistrates Court, name and provision number of law under which Magistrates Court has jurisdiction to decide claim)
(name)
Plaintiff

(name)
Defendant

The plaintiff claims against the defendant relying on the facts claimed in the attached statement of claim.
Nature of claim
(tick appropriate box)
[ ]	debt or liquidated demand
[ ]	motor vehicle death or personal injury 
[ ]	employment death or personal injury 
[ ]	other death or personal injury 
[ ]	other (please specify)

Relief claimed—general
Relief claimed (if a claim is for exemplary damages or aggravated damages, this must be specified—see r 50 (5) (a) (Originating claim—content etc)):
*Interest claimed:
*Interlocutory relief claimed:
Summary judgment *[is/is not] to be applied for.
Plaintiff
*(if the plaintiff is an individual)
Full name:
*[Home/Business] address:
*(if the plaintiff is a corporation)
Name:
(if the corporation is a company or registered body within the meaning of the Corporations Act 2001 (Cwlth))
*[Australian Company Number/Australian Registered Body Number]:
Type of body:
Address of *[registered office/public officer]:
*Representative capacity in which plaintiff sues:
*(if the plaintiff is represented by a solicitor)
Solicitor’s full name:
(if the solicitor practises in a firm of solicitors)
*Solicitor’s firm:
Solicitor’s full business address:
Solicitor’s telephone no:
*Name, address and telephone no of solicitor’s agent:

Address for service of documents
(set out plaintiff’s address for service)
(if represented by a solicitor the following information may be given)
*Document exchange box no:
(if postal address different from address for service)
*Postal address:
*Fax:
*Email address:
Defendant *(so far as known)
*(if the defendant is an individual)
Full name:
*[Home/Business] address:
*(if the defendant is a corporation)
Name:
(if the corporation is a company or a registered body within the meaning of the Corporations Act 2001 (Cwlth))
*[Australian Company Number/Australian Registered Body Number]:
Type of body:
Address of *[registered office/public officer]:
*Representative capacity in which defendant is sued:
Date:
(signature of plaintiff or plaintiff’s solicitor):
(name of plaintiff or plaintiff’s solicitor)

Notice to defendant
You must file a defence, or a notice of intention to respond and a defence, to the originating claim in the Court within 28 days after the day the claim is served on you (see rule 102 (Notice of intention to respond or defence—filing and service).
If you do not file a defence, or a notice of intention to respond and a defence, within this time—
•	the proceeding may be heard in your absence; or
•	default judgment may be entered, or an order made, against you.

(Include the following statements if relevant to the claim)
*Endorsement
(complete this section if the claim is an action under the Civil Law (Wrongs) Act 2002, pt 3.1)
This claim is made for the benefit of the following people:

1.	(Name of person)	(relationship to deceased person)
2.	(Name of person)	(relationship to deceased person)
*Certificate that claim has reasonable prospects of success
(complete this section if the Civil Law (Wrongs) Act 2002, s 188 applies to the action)

I, (solicitor’s full name) certify that I believe, on the basis of provable facts and a reasonably arguable view of the law, that this claim has reasonable prospects of success.

Date:

(signature of plaintiff’s solicitor)

(name of plaintiff’s solicitor)

*omit if, or whichever is, inapplicable