Lodgment No:		

Conveyance Lodgment Form
Complete this form when lodging documents relating to conveyances of land, a Crown lease or a land use entitlement in the ACT

NOTE	Complete all unshaded areas in block letters
Client Name	Address	Contact Name	Client Account No	

Contact details	
Telephone	Email	

Date of first execution 	Name of transferor/seller	Name of transferee/buyer	

Dutiable value	Suburb	Section 	Block	Unit	

Lease purpose clause (circle one)	Residential	Commercial	

Residential land rent lease (circle one)	Yes	No	

Improvements (circle one)	Vacant land	Completed building	Incomplete building	

PRIVACY STATEMENT
All information collected by the ACT Revenue Office is protected by secrecy provisions in Acts administered by the Office and only used for the purposes of those Acts. In addition, personal information provided to the ACT Revenue Office is protected by the Privacy Act 1988 (Cth).  Information (including personal information) is not disclosed to any third party unless authorised by law or with the consent of the person involved.	

DECLARATION FOR ACQUISITION OF DUTIABLE PROPERTY LISTED ON PAGE ONE
To your knowledge:	
1.	Is any Transferor of the property above related to or associated with any Transferee?	        No	        Yes
If YES attach an independent property valuation report  	
2.	Is the property being transferred for less than its dutiable value?1	        No	        Yes
If YES attach an independent property valuation report4	
3.	Are there any other instruments or arrangements under which dutiable property including shares and units will be acquired as part of this transaction?	        No	        Yes
If YES attach details of other dutiable transactions (and completed lodgment form required for each type of transaction)	
4.	Is the transaction listed above a residential ‘off the plan’ purchase?	        No	        Yes
If YES attach a completed Declaration for Residential ‘Off the Plan’ Purchase Agreement Form	
5.	Is the transaction listed above an affordable house and land package?	        No	        Yes
If YES attach a completed Affordable House and Land Package Declaration Form	
6.	Is the transaction listed above part of an arrangement under which other dutiable transactions occurred within the last 12 months with the same transferee (or associated person3) in respect of separate items of dutiable property or separate parts or interests in dutiable property?	        No	        Yes
If YES attach a statement setting out the particulars of the transactions (date, property values, property identifiers)	
7.	Did the vendor use a Real Estate Agent/Auctioneer to sell this property?	        No	        Yes	
I …………………………………………………....... of ……………………………………………………………… being the transferee/transferee’s 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)