Claim Number:

To: The Small Claims Tribunal at

AND:

(here insert name and address of the other parties)

TAKE NOTICE THAT

(here insert name and address of applicant)

Hereby applies for an order that the claim herein be reheard, for the following reasons—

(here set out reasons why a rehearing is sought)

..................................

Signature of applicant

Dated this.................................. day of.. 20..