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

Contact Telephone No.

IMPORTANT:  If any of the transferees listed below, or persons associated with any of the transferees, have entered into more than one transaction with the transferor during a 12-month period, please disclose the details on a separate page.  If unsure please ask our staff.

Lodgment No: (Office use) 

	

Contact Name

Address for correspondence

________________________________________________________________________________________________________________________________________

ACT DUTY
Statement of Change 
in Beneficial Ownership
(for use where no documents executed)

Lodger’s Name

Lodger’s number
(for regular lodgers)

Date of Transaction	Names of Parties

                     Transferor                                      Transferee	Consideration	Market value	Associated persons yes/no?	Suburb	Assessed Value	
							Office Use Only
	
Description of Transaction	

	
For office use only	

I hereby declare that the above information, and supporting information is true and correct.

Signed____________________________________	                                   Name ____________________________________                                    Date___/___/___

 GIVING FALSE OR MISLEADING INFORMATION IS A SERIOUS OFFENCE (Section 338 Criminal Code 2002)
This form is Approved form AF 2006-72 under section 139C of the Taxation Administration Act 1999