Sample Payment Claim Form

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Building and Construction Industry Security of Payment Act 1999 NSW
Government Information Kit
INFORMATION SHEET 10
Sample Payment Claim Form under the
Building and Construction Industry Security of Payment Act 1999 NSW
P
C
AYMENT
LAIM
To (Respondent’s Name):
ABN (where applicable)
Address (ordinary place of business)
Phone Number
Fax Number
This is a payment claim made under the Building and Construction Industry Security of Payment
Act 1999 NSW.
From (Claimant’s Name):
ABN (where applicable)
Address (ordinary place of business)
Phone Number
Fax Number
Contract Details
Project:
Contract Number (where applicable):
Reference date (date when claimant can claim and to
which claim is calculated):
Total amount of this Payment Claim
$
The construction work or related goods and services in respect of which this Payment Claim is
made and the method of calculation of the total amount of the claim are set out in the Attachment(s)
to this Payment Claim.
Signed (Claimant):
Date:
Attachment(s)
Details of Claim (attach other relevant documentation as required) :
Page 1 of 2
March 2003
Caution – Please read the Information Kit’s Disclaimer

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