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

Lodgment No

								

Transfer of Business Assets Lodgment Form

Complete this form when lodging documents relating to the transfer of dutiable business assets 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	

DECLARATION FOR ACQUISITION OF BUSINESS ASSETS (Circle as appropriate)

To your knowledge:

1.	Is any Transferor of the business assets 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 shares, units and land 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 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).

LIST THE VALUE OF THE FOLLOWING COMPONENTS OF THE TRANSACTION, AS APPLICABLE

      ACT Portion     	Non-ACT portion
•	Goodwill (if sales of goods or services have been made to a 
an ACT customer in the 12 months prior to the dutiable transaction);		$----------------------	$------------------
•	Intellectual property (if it has been used or exploited in the ACT in
      the 12 months prior to the dutiable transaction);				$----------------------	$------------------
•	statutory licence(s) or permission(s) under Commonwealth laws
      (if the rights under the licence or permission have been exercised 
      in respect of the Territory in the 12 months prior to the
dutiable transaction); 							$----------------------	$------------------
•	Statutory licence(s) under a Territory law;					$----------------------	$------------------
•	Any goods sold with the business (do not include goods that are
stock in trade, for use in manufacture, held or used for primary 
production, livestock, registered motor vehicles or ships or vessels)		$----------------------	$------------------

TOTAL CONSIDERATION						$                         (1)	$                  (2)

Please provide details under the categories below if the business asset involves Australia-wide items.
•	The gross sales of goods made to ACT customers during the 
last 3 completed financial years preceding this transaction;				$----------------------
•	The gross sales of goods made to ALL customers during the last 3  
completed financial years preceding this transaction.					$----------------------

Dutiable Value 	Total Consideration
(1) + (2)	

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 Information 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 AF2006-69 under section 139C of the Taxation Administration Act 1999