ACT HERITAGE REGISTER— CANCELLATION FORM

The ACT Heritage Register contains details of places and objects of significance to the ACT protected under ACT law. 

This form is for a cancellation proposal, in part or whole, of the heritage registration of a place or object under the Heritage Act 2004 (Part7). 

You are asked to identify the loss of registered heritage values and provide supporting evidence. Each cancellation proposal will be publicly notified as well as being forwarded to each interested person (Heritage Act 2004 s13). It will have a four-week consultation period with public comments invited. 

Any omissions or mistakes in a Register entry do not require the use of this form and can be reported directly to the Heritage Unit on (02) 6207 2166 or email heritage@act.gov.au.

No fee is payable on cancellation. If you need help completing this form, contact (02) 6207 2166. Incomplete or inadequate forms will be returned with feedback. 

DO YOU REQUIRE MORE INFORMATION OR HELP?

For further help, contact the Heritage Unit on (02) 6207 2166 or email heritage@act.gov.au

For more information on the ACT Heritage Council, the Heritage Register or the heritage registration process, please download the relevant information sheets available on the Environment ACT Website at www.environment.act.gov.au under Heritage or by contacting the Heritage Unit.

Approved form AF 2006-245 approved by John Hargreaves MLA, Minister for the  Territory and Municipal Services on 
9 August 2006  under s119 Heritage Act 2004 (approved forms).

LODGING YOUR FORM
Please send this form
o	by mail to:	The ACT Heritage Council, PO Box 158, LYNEHAM ACT 2602 
o	by fax to:	(02) 6207 2200
o	or by hand to:	The ACT Heritage Council, c/o Heritage Unit, Level 2 Tower, Macarthur House, 
12 Wattle Street, Lyneham, ACT 2602

And if possible, email an electronic copy to heritage@act.gov.au. Blank forms are available on the Environment ACT website, however the form will not be accepted without a hardcopy with a signature.

01	DETAILS OF ACT HERITAGE REGISTER ENTRY
 Place   Object	Heritage Register ID:      	Date of Registration:      	
Type:  historic  Aboriginal  natural   other/combined      	
Name of Registration: 	     	
Location: 	      
Address	     
Suburb	
     
Block/Section/District/Division  (If multiple addresses or blocks and sections, list out all)	

02	YOUR DETAILS
Name:	      
Title	      
First Name	      
Surname	
Organisation 	      
Organisation Name (if the organisation is the nominator) 	      
Position	
Postal Address:	      
Postal Address	    
State	     
Postcode	
Telephone:	      
Business Hours	      
After Hours	      
Mobile	
	     
Fax	     
Email	
Do you have any personal association with the place or object?     yes   no
If yes, how would describe yourself:  owner  tenant  neighbour 
 a person with traditional (Aboriginal) affiliation with the place or object   other        	

03	CANCELLATION PROPOSAL

    Full cancellation is requested of the Heritage Register entry 

Details of cancellation: i.e. why is it no longer significant? (with reference to the heritage significance criteria in the Register entry)
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
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__________________________________________________________________________________________
   Partial cancellation is requested of the Heritage Register entry

For Partial Cancellation:
What features are proposed for cancellation? Please attach a map or list if needed and which if any of the intrinsic (or significant) features listed in the Register are no longer considered significant e.g. interiors, exterior elements, archaeological, landscape or natural features, or objects.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Details of cancellation: i.e. why is it no longer significant? (with reference to the heritage significance criteria in the Register entry)
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
04	FURTHER SUPPORTING INFORMATION
Additional attachments can be provided

Provide any known details for the owner/s, unless  same as applicant for cancellation	
Current owner:	      
Name (attach additional details if multiple owners)	
Address:	      
Postal or Street Address	      
State	     
Postcode	
Telephone:	      
Business Hours	      
After Hours	      
Mobile	
	     
Fax	     
Email	
Is the owner/s aware of the cancellation proposal?
  no   yes  some are (indicate which if multiple owners)	
Does the owner/s support the cancellation proposal?
  no  yes,  some do, attach letter/s of support if possible	

Please indicate if any of the following has changed in any substantial way since the Register Entry was notified:

Current physical condition: covering key features (attach photographs)
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Damage or destruction or threats that have reduced or removed its significance: 
__________________________________________________________________________________________
__________________________________________________________________________________________
________________________________________________________________
Changes of use, ownership or any other significance change:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
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Supporting Documentation: Please list any further documentation that will support this cancellation, 
e.g. engineering reports, arboricultural reports, heritage surveys, condition assessments, historic documents, maps, photos, written histories, oral histories, heritage assessment reports (include author, date and name), site recording forms for Aboriginal places/objects (contact the Heritage Unit for blank forms).

Author/s or Source	Title/Description	Date	

			

List all attachments enclosed:
	______________________________________________________
	______________________________________________________
	______________________________________________________
	______________________________________________________
	______________________________________________________

‘I wish to have this heritage registration cancelled, in whole or in part as indicated, in accordance with the Heritage Act 2004. The information provided here is accurate to the best of my knowledge and may be made publicly available for the purpose of cancelling the registration of this place or object, unless otherwise indicated.’
   ‘I allow for my name/organisation to be disclosed as the applicant for a cancellation proposal.’  Your identity is protected under the Federal Privacy Act 1988 and will not be divulged without your consent or as allowed for under that Act.

Signed:  ______________________________
	Date: