ACT REVENUE OFFICE
APPLICATION FOR ENERGY UTILITY REGISTRATION
ENERGY INDUSTRY LEVY 
UTILITIES ACT 2000

Pension Details

Please Note
Please lodge the application promptly – Late lodgement of this application may result in penalties.  
Failure to register as required is an offence with a maximum penalty of 50 penalty units 
(section 54L Utilities Act 2000).

PLEASE PRINT DETAILS CLEARLY
		
Utility Details

Legal Entity
(full legal name -
write on a separate 

sheet if there is
insufficient room 

provided)

Trading Name
or Trust Name

ACN

ABN

Postal Address for Service of Notices

Postcode

Contact Officer

Telephone

 Fax

Email Address

 

Client Number (if known)

If you are already registered with the ACT Revenue Office for a tax or 
duty, please provide the client number previously supplied by this office.

Are you currently registered for the Utilities Network Facilities Tax ?	     Yes                          No  

Energy Utility Type
Tick the box/boxes that best describe the nature of your Energy Industry:
        ELECTRICITY SUPPLY FROM AN 
        ELECTRICITY NETWORK TO     
        PREMISES
	         GAS SUPPLY FROM A GAS     
         DISTRIBUTION NETWORK    
         TO PREMISES	        OTHER ENERGY INDUSTRY   
        SECTOR PRESCRIBED BY     
        REGULATION 	
        ELECTRICITY DISTRIBUTION    
        THROUGH AN ELECTRICITY                          
        NETWORK 	         GAS DISTRIBUTION 
                THROUGH A GAS  
                 DISTRIBUTION NETWORK	

List all directors, legal entity secretaries and officers showing full names, address and title

Directors

Name	Address	Title	

			

(if space is insufficient attach a separate schedule)

Declaration

The Commissioner for ACT Revenue relies on the information provided in this application to register the energy utility for the Energy Industry Levy and to determine if an assessment is required.  Please make sure that the information provided is correct. 

Giving false or misleading information is a serious offence (Part 3.4 of the Criminal Code 2002).

Under Part 3.4 of the Criminal Code 2002 (False or misleading statements, information and documents), the maximum level of punishment for providing false or misleading information is 100 penalty units and/or imprisonment for 1 year.

I, ____________________________________ of _________________________________________________ 
 (full name of person authorised to act for the legal entity)                                                   (name of legal entity)

a)	declare that the information provided in this application is true and correct; and

b)	authorise the ACT Revenue Office to access information about the energy utility held by energy regulators or market managers for the purpose of determining liability for the Energy Industry Levy (Utilities Act 2000).

______________________________________________                             _______________
                            Signature                                                                                        Date

PRIVACY STATEMENT
The information requested in this form or collected under your authorisation above is required by the ACT Revenue Office to determine your Energy Industry Levy liability.  Collection of this information is authorised by the Utilities Act 2000 and the Taxation Administration 
Act 1999.  The information can only be disclosed to another party in the circumstances outlined in the Taxation Administration Act 1999, or as otherwise required by law, or with the consent of the energy utility.

This form is Approved Form AF2007-114 under section 139C of the Taxation Administration Act 1999.

Taxation Administration Act 1999.