3 Empowered by s 82(1)
A[For cases where land is taken]
Claim to compensation under the Public Works Act 1981
To [insert either the Minister of Lands or the name of the local authority, as the case may be]
By a Proclamation or (declaration) dated [date], the land mentioned in table A below, in which I have an interest as described in table B below, has been taken and vested in the Crown or [name of local authority] for the purpose of [name of public work mentioned in Proclamation or declaration]:
[For cases where injurious affection also claimed add following paragraph]
And the land mentioned in table C below, adjacent to the land so taken in which I have an interest as described in table D below, will be injuriously affected by the said work because [state items of claim, with a reference number to each, and give in each case full particulars of the nature and extent of the claim]: I hereby claim the sum of $[amount] as compensation for all loss arising out of the taking of the said land and the construction of the said public work (which sum is supported by the valuation attached) [delete if not applicable] and which is made up as follows:
| $ |
Sum claimed as compensation for land taken:
[Give full particulars of nature and extent of claim and how compensation has been calculated with, where applicable, reference to supporting valuation.]
Sum claimed for disturbance:
[Give full particulars of nature and extent of claim.]
Sum claimed for damage:
[Give full particulars of nature and extent of claim.]
Sum claimed for injurious affection:
[Give full particulars.]
Total claim:
Dated at [place, date].
Claimant: [full name]
Address for service:
Signature:
Table A
Description of land taken
[Describe the area and situation of the land taken, giving name of survey district, and number of block and section as in the Proclamation or declaration and the Gazette reference or other reference to the document taking title.]
Table B
Nature of interest in land taken
[State in full the nature of the interest; and if the land is leased or encumbered, or subject to any easement, give particulars of the lease or encumbrance or easement.]
Table C
Description of land injuriously affected
[Describe the area and situation of the land injuriously affected, giving name of survey district, and number of block and section, or other means of identification.]
Table D
Nature of interest in land injuriously affected
[State in full the nature of the interest; and if the land is leased or encumbered or subject to any easement, give particulars of the lease or encumbrance or easement.]
Notes
B[For cases where land is injuriously affected or damaged, but where no land is taken]
Claim to compensation under the Public Works Act 1981
To [insert either the Minister of Lands or the name of the local authority, as the case may be]. The public work described in table A below has been or is about to be executed by your authority, and the land described in table B below, in which I have an interest as described in table C below, has been or will be injuriously affected or damaged by the work because [state items of claim with a reference number to each, and give in each case full particulars of the nature and extent of each item].
I claim the sum of $[amount] as compensation for all loss arising out of the execution of the said work, which sum is made up as follows:
| $ |
Sum claimed for injurious affection:
Sum claimed for damage:
Sum claimed for disturbance:
[State reference number and short heading of each item of claim previously detailed, and the amount claimed in respect of each item separately.]
Total claim:
Dated at [place, date].
Claimant: [full name]
Address for service:
Signature:
Table A
Description of public work
[State description and location of public work.]
Table B
Description of land injuriously affected
[Describe the area and situation of the land injuriously affected, giving name of survey district, and number of block and section, or other means of identification.]
Table C
Nature of interest in land injuriously affected
[State in full the nature of the interest; and if the land is leased or encumbered or subject to any easement, give particulars of the lease or encumbrance or easement.]