LAND TITLES
OFFICE OF REGULATORY SERVICES
Department of Justice and Community Safety

APPLICATION TO NOTE CHANGE OF NAME ON A CAVEAT		
Form 104 - CNX	

	Land Titles Act 1925		

IMPORTANT INFORMATION
This form is to be used to lodge an application to note change of name on a caveat under the Land Titles Act 1925 (the Act).  You can access the Act at www.legislation.act.gov.au.  You may also obtain further information and forms at www.ors.act.gov.au. 
	
PRIVACY INFORMATION
The Act authorises the Registrar-General to collect the information required by this form.  The Registrar-General provides identifiable information to various agencies including, but not limited to, the ACT Planning and Land Authority, ACT Treasury, Canberra Connect and ACTEWAGL for conveyancing, municipal account administrative, statistical and valuation purposes.  These agencies may also use this information to prepare and sell property sales reports to commercial organisations concerned with the development, sale or marketing of land.
	
CONTACT INFORMATION	
Lodge in person at the Office of Regulatory Services:	255 Canberra Avenue, Fyshwick ACT 2609	
Office Hours:	9:00am to 4:30pm Monday to Friday	
General enquiries telephone number:	(02) 6207 0491	
Website address:	www.ors.act.gov.au 
	
INSTRUCTIONS FOR COMPLETION
•	The certificate of title is not required for lodgement of this document.
•	All information should be typed or clearly printed.  If completing this form by hand please use a solid black pen only.  
•	This office will not accept lodgement of this form if it is not completed in full.
•	Any alteration to information provided on this form must be struck through with a black pen.  Substitute information must be clear and all parties must sign in the margin.  Do not use correction fluid or tape.
•	Ensure all required documents are attached.  If there is insufficient space in any panel, please use an Annexure Sheet.
•	Execution by:
a)	A Natural Person – Should be witnessed by an adult person who is not a party to the document.
b)	Attorney – if this document is executed by an Attorney pursuant to a registered power of attorney, it must set out the full name of the attorney and the form of execution must indicate the source of his/her authority e.g. “AB by his/her attorney XY pursuant to Power of Attorney ACT Registration No…… of which he/she has no notice of revocation”.  (This execution requires a witness).
c)	Corporation – Section 127 of the Corporations Act provides that a company may now validly execute a document with or without using a Common Seal if the document is signed by:
i.	Two directors of the company;
ii.	A director and a secretary of the company; or
iii.	Where the company is a proprietary company and has a sole director who is also the sole company secretary, that director.   (This execution does not require a witness).
•	The following forms of execution are suggested –
a)	With A Common Seal
The common seal of ABC Pty Ltd/Ltd ACN…………………
was affixed in the presence of-
...................................(signature)	
...................................(director/secretary)*
(*repeat if necessary i.e. if two directors signing.  If signing as sole director and sole secretary, state ‘director/secretary’).  (This execution does not require a witness).
b)	Without A Common Seal
Signed by ABC Pty Ltd/Ltd ACN……………………
...................................(signature)	
...................................(director/secretary)*
(*repeat if necessary i.e. if two directors signing.  If signing as sole director and sole secretary, state ‘director/secretary’)  - (This execution does not require a witness).

	LAND TITLES
OFFICE OF REGULATORY SERVICES
Department of Justice and Community Safety

APPLICATION TO NOTE CHANGE OF NAME ON A CAVEAT		
Form 104 - CNX	

	Land Titles Act 1925		

LODGING PARTY DETAILS	
Name	Postal Address	Contact Telephone Number	
     	     	     	

TITLE AND LAND DETAILS	
Volume & Folio	District/Division	Section	Block	Unit	
     	     	     	     	     	

REGISTERED CAVEAT NUMBER (Associated Dealing Number)	
     	

FULL NAME OF CAVEATOR ON REGISTER TO BE CHANGED (As it appears on title)	
     	

NEW NAME OF CAVEATOR (Full Name - Surname Last)	
     	

REASON FOR CHANGE OF NAME (Please provide details as to the Change of Name)	
     	

EVIDENCE PROVIDED TO SUPPORT CHANGE OF NAME  (Please provide registration details of Marriage Certificate, Change of Name Cert etc)	
     	

DATE	
     	

CAVEATOR’S EXECUTION	

Print full name of Caveator

     

Signature of Caveator
	
Print full name and address of witness 

     

Signature of witness

STATUTORY DECLARATION	

I,  of                                                                                                         ,                                                                     

                                                                    (occupation)

Am the same person as                                                                                                        , the registered Caveator in Caveat Number…                     in Crown Lease / Certificate of Title Volume                      Folio                     

And I make this solemn declaration by virtue of the Statutory Declarations Act 1959, and subject to the penalties provided by that Act for the making of false declarations, conscientiously believing the statements contain in this declaration to be true in every particular.

STATUTORY DECLARATION EXECUTION	

Declared at                       on

the                        day of                                                        20

Signature of person making the declaration	Signature of person before whom the declaration is made

     

Full name, qualification* and address of person before whom the declaration is made (in printed letters) (*Must be authorised under the Statutory Declarations Act 1959)	

OFFICE USE ONLY	
Lodged by		Attachments / Annexures		
Data entered by		Supporting Docs Sighted		
Registered By		Registration date