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

								

Leases or Licences Lodgment Form

Complete this form when lodging a lease or licence to use land or to vary an existing lease or licence agreement which alters the cost of a lease or licence.

                                                                                  		                  

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

Lessor/Licensor                                          Lessee/Licensee               	

	
LOCATION OF LEASED/LICENSED PREMISES	
Suburb	Section	Block	Unit	

PERMITTED USE OF PREMISES
		
LETTABLE AREA (M2)	
	
TOTAL AREA WHERE OUTGOINGS FOR LETTABLE AREA ARE APPORTIONED 		
COMMENCEMENT DATE 	
	
TERM OF LEASE/LICENCE  
		
OPTION PERIODS (IF ANY)
		
IS GST PAYABLE UNDER THE AGREEMENT?  

DECLARATION FOR ACQUISITION OF LEASE OR LICENCE (Circle as appropriate)

To your knowledge:

1.	Is the Lessor/Licensor related to any Lessee/Licensee?       	       NO		YES

2.	Are there any other instruments or arrangements under which 	       NO		YES
    dutiable property including business assets or 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).

COST OF LEASE/LICENCE
Cost of Lease/Licence (to be completed where a Disclosure Statement issued pursuant to the Leases (Commercial & Retail) Act 2001 has not been attached, or not required to be provided under that Act).

                                                                                                                      	$ PA	
BASE RENT & 
METHOD FOR ANNUAL INCREASES		
TURNOVER RENT & CALCULATION METHOD		
TOTAL OUTGOINGS PAYABLE BY THE TENANT

	AIR CON/VENTILATION	
	
	BUILDING SYSTEM MAINTENANCE		
	COMMON AREA SERVICING		
	CAR PARKING		
	CLEANING		
	ELECTRICITY
		
	FIRE PROTECTION		
	GAS
		
	MANAGEMENT COSTS		
	WATER & SEWERAGE		
	PEST CONTROL		
	SECURITY		
	OTHER
		
APPORTIONMENT METHOD FOR LETTABLE AREA		
GENERAL RATES AND LAND TAX		
VALUE OF IMPROVEMENTS/ADDITIONS (EXCLUDING FITOUT)
		
ROYALTIES & PREMIUMS		

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.  PLEASE DO NOT GIVE A % FIGURE ALONE.

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 lessor / licensor/ 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 AF2006-71 under section 139C of the Taxation Administration Act 1999