Lodgment No

ACT REVENUE OFFICE
PO Box 293 Civic Square ACT 2608
Phone:    (02) 6207 0028
Fax:        (02) 6207 0026
Website: www.revenue.act.gov.au

								

Transfer of Unlisted Shares or Units Lodgment Form

Complete this form when lodging documents relating to the transfer of unlisted marketable securities (unlisted shares or units)

                                                                                  		                  

PLEASE COMPLETE UNSHADED AREAS IN BLOCK LETTERS

Client Name	Address	Contact Name	Contact Telephone No	
				
		Client Account No	Email Details	

Date of
First
Execution	                                            Names of Parties

Transferor                                                          Transferee	

Entity in which shares or units are being transferred

Number of Shares
	Purchase Price	Market value	

You must attach to this form:
•	Your transfer instrument or agreement to transfer (if no documents, complete the Statement of Change in Beneficial Ownership Lodgment Form);
•	The most recent audited financial statements or a certified copy of the financial management accounts of the company or trust in which the shares or units are being transferred and;
•	If the company or trust has more than one class of shares or units, the articles of association outlining the rights that attach to each class of shares or units.

DECLARATION FOR ACQUISITION OF UNLISTED SHARES OR UNITS (Circle as appropriate)

To your knowledge:

1.	Is any Transferor of the shares or units related to any Transferee?       NO		YES

If YES then attach an independent property valuation report. 

2.	Is the property being sold for less than its dutiable value?		       NO		YES

If YES then attach an independent property valuation report.

3.	Are there any other instruments or arrangements under which             NO		YES
	dutiable property including business assets or land, will 		       
											       If YES then attach details of other dutiable	
	acquired as part of this transaction?				       Transactions (and completed lodgment form
	required for each type of transaction).

4.	Is the transaction listed above part of an arrangement under which      NO		YES 
other dutiable transactions occurred within the last 12 months             
with the same transferee (or associated person) in respect of	       If YES then attach a statement setting out
separate items of dutiable property or separate parts or interests         the particulars of the other transactions
of dutiable property ?       						       (date, property values, property identifiers).

5.	Does the company or trust in which the shares or units are	       NO		YES
being transferred, hold any interest in ACT land ?                                        
If NO, then go directly to the Declaration at the end of this form and sign.		
If YES then complete the ACT Land details below.

ACT Land details	
Suburb	Section 	Block	Unit	

				

 

6.	Does this acquisition give the transferee, either alone or in 	     NO  		YES
combination with any other associated persons, a greater               	
than 50% percent interest in the company or trust in which             If NO then go directly to the Declaration
shares or units are being transferred. 			                 at the end of this form and sign.
If YES then you must provide a diagrammatic outline of the relevant holdings of associated persons before and after the relevant acquisition identified above. You must also complete the details in the Details of Acquisitions Table below

  

Details of Acquisitions  (including those by associated persons) since 
1 March 1999

Date	Total number of issued shares/units 	Total number of acquired shares/units	Market value of the ACT land at the time	

				

				

PRIVACY STATEMENT

•	The information in this form is required by the ACT Revenue Office (ACTRO) to determine your liability for duty. All information collected is stored in hard-copy and/or electronic form in accordance with the Territory Records Act 2002 and is protected by secrecy provisions in Acts administered by the ACTRO. 
•	In addition, personal information you provide to the ACTRO is protected by the Privacy Act 1998 (Cwlth).
•	Any information collected from you is only to be used for the purpose of the Acts administered by the ACTRO. The information you provide, is not disclosed to third parties unless authorised by law, or with your consent. 

	
  	DECLARATION

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

  being the transferee/transferee’s authorised agent (delete whichever is not applicable) declare that the above 
  information is, to the best of my knowledge, true and correct and in conformity with the agreement between 
  the parties.

  I also acknowledge that I have read and understand the Privacy Statement. 

  Signed ____________________________________	Date                                  

GIVING FALSE OR MISLEADING INFORMATION IS A SERIOUS OFFENCE
(Section 338 Criminal Code 2002)

This form is Approved form AF2006-3 under section 139C of the Taxation Administration Act 1999