Form 4—Application for determination of Form 4—Application for determination of day of withdrawal from amalgamated organisation

## Form 4—Application for determination of day of withdrawal from amalgamated organisation (subregulation 107(5)) Fair Work (Registered Organisations) Act 2009, subsection 109(5) APPLICATION FOR DETERMINATION OF DAY OF WITHDRAWAL FROM AMALGAMATED ORGANISATION TO: THE FEDERAL COURT OF AUSTRALIA I/We, (full name(s) of applicant(s)), the applicant(s) listed in the schedule to this application\*, apply for: (a) a determination of the day on which the withdrawal of (name of constituent part of amalgamated organisation) from (name of amalgamated organisation) is to take effect; (b) orders to apportion the assets and liabilities of (name of amalgamated organisation) between (name of amalgamated organisation) and (name of constituent part of amalgamated organisation);\* (c) other orders in connection with giving effect to the withdrawal\*. \*Omit if inapplicable. INFORMATION 1. Details of the eligibility of the applicant(s) to make the application in accordance with subsection 109(3) of the Act. 2. A statement that more than 50% of the formal votes cast in a ballot are in favour of the constituent part withdrawing from the amalgamated organisation. 3. Details of the assets and liabilities of the constituent part before it, or the organisation of which it was a State or Territory branch, was de‑registered in connection with the formation of the amalgamated organisation. 4. Details of any change in the net value of those assets and liabilities since the amalgamation. 5. Details of the creditors of the amalgamated organisation and the nature of their interest. 6. Other information to which the applicant wishes the Court to have regard. Dated 20 . ................................................ Signature of applicant(s)