Forms for mediation


For all farm debt mediation requests, notices and applications, farmers and creditors may use forms approved by the Secretary of the Department of Jobs, Precincts and Regions.

For general information on the forms, contact a Farm Debt Mediation Officer on 136 186 or

All requests for mediation need to be sent to:


Farm Debt Mediation Officer
PO Box 2392
Level 26, 1 Spring Street
Melbourne, Victoria, 3000

Forms related to creditor-initiated mediation

Forms related to farmer-initiated mediation

Farmer application for a prohibition certificate

Form 10 - Section 13: Application for Prohibition Certificate (WORD - 43.5 KB)

Creditor application for an exemption certificate

Form 4 - Section 15: Application for Exemption Certificate (WORD - 58.0 KB)

Related information and documents

The following resources should be included with a Form 1 notice of availability of mediation.

Page last updated: 13 Jul 2020