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

								

Conveyance Lodgment Form

Complete this form when lodging documents relating to conveyances of land, a Crown lease or a land use entitlement in the ACT.

                                                                                  		                  

PLEASE COMPLETE ALL 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	
			
Dutiable Value 	Suburb	Section	Block	Unit	

LEASE PURPOSE CLAUSE - RESIDENTIAL OR COMMERCIAL (CIRCLE WHICHEVER IS APPLICABLE)	

IMPROVEMENTS – VACANT LAND, COMPLETED BUILDING OR INCOMPLETED BUILDING 
                           (CIRCLE WHICHEVER IS APPLICABLE)	

DECLARATION FOR ACQUISITION OF DUTIABLE PROPERTY LISTED ABOVE (Circle as appropriate)

To your knowledge:

1.	Is any Transferor of the property above 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?a	     	NO			YES

If YES then attach an independent property valuation reportc

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

4.	Is the transaction listed above a residential ‘off the plan’ purchase?        	NO			YES

If YES then attach a completed Residential ‘Off the Plan’ Lodgment Form

5.	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 
separate items of dutiable property or separate parts or interests          	out the particulars of the other of dutiable property?       	 						transactions (date, property values, 
										property identifiers).

6.	Did the vendor use a Real Estate Agent/Auctioneer to sell this property?	NO			YES

_______________________________________________________________________________________________

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 AF2006-66 under section 139C of the Taxation Administration Act 1999