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

								

Franchise Lodgment Form

Complete this form when lodging a franchise agreement or to vary an existing franchise agreement which alters the cost of a franchise agreement.

                                                                                  		                  

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 & Address of Parties

Franchisor                                                Franchisee               	

	
LOCATION OF FRANCHISEE OPERATIONS	
Suburb	Section	Block	Unit	

AMOUNTS PAYABLE                                                   $PA	
ALL AMOUNTS PAYABLE FOR GRANT OF FRANCHISE	
	
RENEWAL FEES		
ESTABLISHMENT FEE		
RIGHT TO USE GOODWILL		
RIGHT TO USE INTELLECTUAL PROPERTY, SYSTEMS & PROCESSES		
USE OF GOODS
		
PERCENTAGE OR TURNOVER FEE		
ANY OTHER AMOUNT PAYABLE FOR EXERCISE OF FRANCHISEE RIGHTS
		
NOTE: WHERE FIGURES ARE ESTIMATES, THEY SHOULD BE SO MARKED. DETAILS OF THE METHOD USED TO ARRIVE AT THE ESTIMATED FIGURES MUST ALSO BE PROVIDED.

DECLARATION FOR ACQUISITION OF FRANCHISE (Circle as appropriate)

To your knowledge:

1.	Is the Franchisor related to any Franchisee?		       	     NO		YES

2.	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 
	be acquired as part of this transaction?	transactions (and completed lodgment form required for each type of transaction).

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 Franchisee / 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 AF2006-70 under section 139C of the Taxation Administration Act 1999