Australian
  Capital Territory
    Government

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Date Received

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Receiving Officer

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Land (Planning and Environment) Act 1991 – Form 5
Application for the Grant of a 
Further Crown Lease

When should you use the application to apply for a further lease?

Privacy Notice
The personal information on this form is being collected to enable processing of your application. The information that you provide may be disclosed to the ACT Revenue Office and the Registrar-General’s Office. The information may be accessed by ACTEW Corporation and commercial organisation interested in building information.

The form is required to apply for a further Crown Lease for land within the ACT either for the same term as the original lease or for an additional term.

Part 1: Lease/Site details
If more than one lease/site, attach the following details for each lease/site.
                                           Block  ______________
                                         Section  ______________
                        Unit (if applicable)  ______________
                                          Suburb  ___________________________________________________________
                                          District  ___________________________________________________________
                               Street Number  ______________
                                Street Name  _________________________________	Postcode _____________
______________________________________________________________________

Part 2: Applicant details

                                            Surname  _______________________________________________________
                                         First Name  _______________________________________________________
                                 Company Name  _______________________________________________________
    Australian Company Number (ACN)  _______________________________________________________
            If a company, position held
		within the company  _________________________________________________________
                                 Postal Address  _________________________________________________________
                                             Suburb  _________________________________________________________
                                  State/Territory  ___________________           Postcode  _____________________
        Phone Number (business hours)  _________________________________________________________
                                      Fax Number  _________________________________________________________
      Email  ____________________________________________________________________________________

All lessees must sign authorising the lodgement, and in doing so give authority to the applicant to negotiate any dealings with the application through to its determination by the relevant authority, or a Power of Attorney must be attached. If there are more than two lessees, please ensure that details and authorisation are attached to the application for each lessee.

If the lessee is a registered company, organisation or government agency you must execute this application in the proper manner for that company, organisation or government agency. For example, if the lessee is a community organisation, the full name of the community organisation must be stated and the signatory must  identify what position of authority he/she holds in the organisation.

To verify the signature of a lessee who is other than a registered company, i.e. a community, an organisation or government agency, a Letter of Authority must be supplied when lodging the application that empowers the signatory to sign on the behalf of that organisation or government agency.

Any application made over a site which has been Unit Titled will require Approval in accordance with the articles of association for that units plan.

Part 3: Lessee (Owner) details

1st Lessee’s details
                                                Surname  __________________________________________________________
                                             First Name  __________________________________________________________
                                     Company Name  __________________________________________________________
       Australian Company Number (ACN)  __________________________________________________________
            If a company, position held
		within the company  ___________________________________________________________
                                      Postal Address  __________________________________________________________
                                                  Suburb  __________________________________________________________
                                       State/Territory  ___________________            Postcode  _____________________
           Phone Number (business hours)  __________________________________________________________
                                         Fax Number  ___________________________________________________________
       Email  _______________________________________________________________________________________

 * Lessee must sign Part 5 of the application form.

2nd  Lessee’s details
                                               Surname  __________________________________________________________
                                            First Name  __________________________________________________________
                                    Company Name  __________________________________________________________
      Australian Company Number (ACN)  ___________________________________________________________
              If a company, position held
		 within the company  ___________________________________________________________
                                         Postal Address  ________________________________________________________
                                                     Suburb  ________________________________________________________
                                         State/Territory  ____________________________     Postcode  _______________
               Phone Number (business hours)  ________________________________________________________
                                             Fax Number  ________________________________________________________
      Email  _______________________________________________________________________________________

* Lessee must sign Part 5 of the application form.

Form of words in attestation/signing legal documents (e.g. The Common Seal of …… was hereto affixed in the presence of …………)

_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Part 4: Summary Information

Type of lease the applicant is seeking
Non-Rural     
Commercial          Residential            Industrial              Unit Title           Other    
Number of years:           99 years              Same as original term             Other (specify)          
Rural (lease to accord with current policies)
	Type of lease the applicant is seeking
	   Long Term               Short Term
Please nominate the form of payment:
	Lump Sum          Partial lump sum plus 30 years of remainder               30 year payout
	Number of approved dwellings on site
	Does the purpose clause of the lease allow for agistment?
	If yes how many horses do you agist?   
Please Note: The grant of a further crown lease for rural purposes is subject to conditions.

Part 5 : Applicant’s & Lessee’s declaration

I/we the undersigned, hereby apply for the grant of a Further Crown Lease as specified in this application;

I/we hereby authorise ACT Planning and Land Authority Officers to access the subject property(s) for the purpose of evaluating the proposal;

I/we understand that the requirements set out in this form are a minimum only and that additional information may be requested during processing; and

I/we declare that all the information given on this form and its attachments is true and complete.

CONFLICT OF INTEREST DECLARATION:    Does the applicant or lessee have any association with ACT Planning and Land Authority staff?
 No                          Yes

If yes, please provide details:  ________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________

Applicant’s Signature(s)  __________________________________	Date  ______________________

1st Lessee’s Signature(s)  __________________________________	Date  ______________________

2nd Lessee’s Signature(s)  _________________________________	Date  ______________________