ACT REVENUE OFFICE
APPLICATION FOR UTILITIES NETWORK FACILITIES
TAX REGISTRATION
Utilities (Network Facilities Tax) Act 2006

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 250 penalty units (section 10 Utilities (Network Facilities ) Tax Act 2006).

PLEASE PRINT DETAILS CLEARLY

		
Company Details

Name of 
Company, 

Association,
Trustee,

Partnership/Joint
Venture or
Individual

(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 any other tax
or duty, please provide the client number previously supplied by this office.

Utility Type
Choose from the following by circling the numbers that best describe the nature of your network infrastructure:

01    ELECTRICITY TRANSMISSION NETWORK
	03    GAS TRANSMISSION NETWORK	05    SEWERAGE NETWORK	
02    ELECTRICITY DISTRIBUTION NETWORK	04    GAS DISTRIBUTION NETWORK	06	WATER NETWORK
	
07    TELECOMMUNICATIONS NETWORK
	08    OTHER NETWORK PRESCRIBED BY     REGULATION

List all directors, company 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 company for the Utilities (Network Facilities) Tax 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 company)                                                        (company name)

declare that the information provided in this application is true and correct.

                 Date						             Signature

PRIVACY STATEMENT
The information requested in this form is required by the ACT Revenue Office to determine your Utilities (Network Facilities) Tax liability.  Collection of this information is authorised by the Utilities (Network Facilities Tax) Act 2006 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.

This form is Approved Form AF2007-24 under section 139C of the Taxation Administration Act 1999.