(Office use)

Lodgment Number

ACT REVENUE OFFICE
PO Box 293 CIVIC SQUARE  ACT  2608

LEASES APPLICATION FORM

For Chapter 5 of the Duties Act 1999 a lease includes a licence.

Where no disclosure statement issued pursuant to the Leases (Commercial and Retail) Act 2000 has been provided, this form is to be completed when lodging a lease to use land or a variation to an existing lease agreement which increases the cost of the lease agreement.

Lodger’s Name 

Contact Name

__________________________________________________________________________________________________________________________________________________________________________________________

Address for correspondence

Lodger’s Number 

(for regular lodgers)

Telephone Number

(  )

Date of First Execution	Name  & Address of Parties	
	Lessor / Licensor	Lessee / Licensee	

	

     Section 1: General Details
						 					
PREMISES ADDRESS
		
PERMITTED USE OF PREMISES
		
LETTABLE AREA (M2)	
	
TOTAL AREA WHERE OUTGOINGS FOR LETTABLE AREA ARE APPORTIONED 		
COMMENCEMENT DATE 	
	
TERM OF LEASE (IF NOT FINANCIAL YEAR, PLEASE SPECIFY PERIOD)
		
OPTION PERIODS (IF ANY)
		
IS GST PAYABLE  UNDER THE AGREEMENT (YES/NO) 
		
Section 2: Cost of Lease

                                                                                                                      	$ P.A.	
BASE RENT & 
METHOD FOR ANNUAL INCREASES
		
TURNOVER RENT  & 
CALCULATION METHOD
		
TOTAL OUTGOINGS PAYABLE BY THE TENANT

	AIR CON/ VENTILATION	
	
	BUILDING SYSTEM MAINTENANCE		
	COMMON AREA SERVICING		
	CAR PARKING		
	CLEANING		
	ELECTRICITY
		
	FIRE PROTECTION		
	GAS
		
	MANAGEMENT COSTS		
	RATES AND LAND TAX		
	WATER & SEWERAGE		
	PEST CONTROL		
	SECURITY		
	OTHER
		
APPORTIONMENT METHOD FOR LETTABLE AREA	
	
VALUE OF IMPROVEMENTS/ADDITIONS (EXCLUDING FITOUT)		
ROYALTIES & PREMIUMS

NOTE: WHERE FIGURES ARE ESTIMATES, THEY SHOULD BE SO MARKED. DETAILS OF THE METHOD USED TO ARRIVE AT THE ESTIMATED FIGURES MUST ALSO BE PROVIDED.

 DECLARATION

I ………………………………………………. of……………………………………………………………………………………….

being the lessor / lessor’s authorised agent (delete whichever is inapplicable) declare that the above information (including actual and estimate figures) is to the best of my knowledge, in conformity with the lease agreement between the parties.

Signed____________________________________	                                          Date_____/_____/_____

GIVING FALSE OR MISLEADING INFORMATION IS A SERIOUS OFFENCE
This form is Approved Form AF2004-11 under section 139C of the Taxation Administration Act 1999