Lodging Party

Box Number

CNSL
Form 010

APPLICATION TO NOTE CHANGE OF NAME 
ON SUBLEASE OR UNDERLEASE

PRIVACY COLLECTION STATEMENT (PRIVACY ACT 1988 (C’WLTH)) OVERLEAF

The registered proprietor of the estate and interest described below applies to have a change of name recorded in the Register.

1. LAND
Vol:Fol	Edition	District/Division	Section	Block	Unit	Instrument No/
Associated Dealing No	
	
     	     	     	     	     	     	     		

2. NAME ON SUBLEASE OR UNDERLEASE TO BE CHANGED
     	

3. NEW NAME
     	

4. EXECUTION
Signed by Applicant (New name only)

Signature of applicant		Full name of witness

Signature of witness 	

5. STATUTORY DECLARATION

I,                                                                                                 of                                                                                                         , 

                                                                     (occupation)

Am the same person as                                                                                                        , the registered proprietor (or one of the registered proprietors) in Sublease or Underlease No                                    for Crown Lease / Certificate of Title Volume                      Folio                     

And I make this solemn declaration by virtue of the Statutory Declarations Act 1959, and subject to the penalties provided by that Act for the making of false declarations, conscientiously believing the statements contain in this declaration to be true in every particular.	

	

Declared at                                                                             on

the                        day of                                                        20

Signature of person making the declaration		Signature of person before whom the declaration is made

Full name, qualification* and address of person before whom the declaration is made (in printed letters) (*Must be authorised under the Statutory Declarations Act 1959)	

6. OFFICE USE ONLY
Examined by	 	Vol:Fol:Ed/Production No
(If applicable)		
Data Entered by		Certificates Lodged
(Compliance/Occupancy)		
		Attachments/Annexures		
Registered by		Registration Date		
PRIVACY STATEMENT
S.43 of the Land Titles Act 1925 (LTA) authorises the Registrar-General to collect the information required by this form for the establishment and maintenance of the Land Titles Register.  S.65-67 LTA requires that the Register be made available to any person for search, upon payment of a fee. The information is regularly provided to various ACT Government agencies, including the ACT Department of Urban Services, ACT Planning and Land Authority (the Authority), ACT Treasury, Canberra Connect and ActewAGL for conveyancing, municipal account, administrative, statistical and valuation purposes.  The Authority and agencies within the ACT Department of Urban Services may also use the information supplied to prepare and sell property sales reports to commercial organisations concerned with the development, sale or marketing of land.  	
SCHEDULE OF NOTES
•	This form should be used to change a proprietor’s name in respect to one or more subleases.
•	Documents must be typed, or completed in black ink or biro.
•	Alterations to information entered on the form should be made by crossing out (not erasing or obliterating by painting over) and should be initialled by all parties.
•	If there is insufficient space in any panel use an annexure sheet.
•	Volume, Folio and Edition references must be given.  
•	Provide the full details of the name as currently on the Land Titles Register.
•	Provide the details of the new name in full that will be placed on the Register.
•	It will be necessary to complete this Statutory Declaration regarding the Change of Name of a person or attach a search from the Australian Securities and Investments Commission (ASIC) for a corporation or company.
•	Execution by
•	A Natural Person – should be witnessed by an adult person who is not a party to the document.
•	Attorney – if this document is executed by an Attorney pursuant to a registered power of attorney, it must set out the full name of the attorney and the form of execution must indicate the source of his/her authority eg. “AB by his/her attorney XY pursuant to Power of Attorney ACT Registration No…… of which he/she has no notice of revocation”.
•	Corporation – Section 127 of the Corporations Act provides that a company may validly execute a document with or without using a Common Seal if the document is signed by:

a.	Two directors of the company;
b.	A director and a secretary of the company; or
c.	Where the company is a proprietary company and has a sole director who is also the sole company secretary, that director.   Please identify that the director is a sole director on the form.
The following forms of execution are suggested –
With A Common Seal
The Common Seal of ABC Pty Ltd/Ltd ACN…..
was affixed in the presence of-
...................................(signature)	
...................................(director/secretary)*
(*repeat if necessary ie if two directors signing.  If signing as sole director and sole secretary, state ‘director/secretary’) 
Without A Common Seal
Signed by………Pty Ltd/Ltd ACN……..
...................................(signature)	
...................................(director/secretary)*
(*repeat if necessary  ie if two directors signing.  If signing as sole director and sole secretary, state ‘director/secretary’) 

NB	The normal witnessing provisions in the Land Titles Act 1925 do not apply to execution by a corporation as above, but do apply to execution by the attorney of a corporation.