This form should be completed when the owner/lessee of 
land in a registered community title scheme proposes to
sell or dispose of land that is to be developed or further
developed in accordance with the community title scheme.

Lot(s) in Community Title Scheme to be assigned Please Print

Block	

Section

Suburb

Community Title Scheme Number

	
		
Street Address	

Postcode	

Lessee (owners) details Please Print

1st Lessee’s details

Surname	
		First Name		
		
Company Name	

              Postal Address	

Suburb	
		State			Postcode		
				
Phone Number Business Hours			Mobile		
		
Email Address

2nd Lessee’s details

Surname	
		First Name		
		
Company Name	

              Postal Address	

Suburb	
		State			Postcode		
				
Phone Number Business Hours			Mobile		
		
Email Address

Buyers details Please Print

1st buyers details

Surname	
		First Name		
		
Company Name	

Postal Address	

Suburb	
		State			Postcode		
				
Phone Number Business Hours			Mobile		
		
Email Address	

2nd buyers details

Surname	
		First Name		
		
Company Name	

Postal Address	

Suburb	
		State			Postcode		
				
Phone Number Business Hours			Mobile		
		
Email Address	

Conflict of Interest Declaration

Does the lessee or buyer have any association with Planning and Land Authority staff?	•	NO
•	YES	
If YES - please provide details:	

NOTE: There are penalties for deliberately giving false and misleading information. The Planning and Land Authority or Minister may revoke an approval if satisfied that the approval was obtained by fraud or misrepresentation.

Lessees Declaration

I/we the undersigned, hereby apply to assign land under a registered community title scheme on the land specified in this application; and

I/we declare that all the information given on this form and its attachments is true and complete.

If signing on behalf of a company or organization:

I/we the undersigned, declare I/we have the appropriate delegation or authority to sign on behalf of the company or organization.

1st Lessee’s Signature	
	Date		

2nd Lessee’s Signature	
	Date		

Buyers Declaration

I/we the undersign, hereby undertake to develop the land in accordance with the registered community title scheme on the land specified in this application; 

I/we understand that payment of a security may be required to be paid; and

I/we declare that all the information given on this form and its attachments is true and complete.

If signing on behalf of a company or organization:

I/we the undersigned, declare I/we have the appropriate delegation or authority to sign on behalf of the company or organization.

1stBuyer’s Signature	
	Date		

2nd Buyer’s  Signature	
	Date		

Contact Details:
Environment and Sustainable Development Directorate
Customer Service Centre
GPO Box 1908, Canberra City 2601
16 Challis Street, Dickson ACT 2602
Business Hours: 8.30am to 4.30pm weekdays (excluding Public Holidays)
Phone: (02) 6207 1923		Fax: (02) 6207 1925		TTY: (02) 6207 2622
Email: actpla.customer.services@act.gov.au	Website: www.actpla.act.gov.au

Privacy Notice
The personal information on this form is being collected to enable processing of your application.  Collection of personal information is authorised by the Community Title Act 2001.  The information that you provide may be disclosed to Government Agencies such as the ACT Revenue office and the Registrar-General’s Office.