This notice is to be used when the applicant for a development application (DA) wishes to have the change of use charge determined under section 276D of the Planning and Development Act 2007. This form is taken to be notice to the commissioner for revenue. 
The following conditions must be met in order to transfer to the new provisions:
•	The development application involving a proposal to vary a Crown lease was lodged, with fees being paid, prior to 1 July 2011; 
•	The change of use charge had not yet been determined by the Planning and Land Authority prior to the date of making this application; and
•	This application is made by the DA applicant before 1 October 2011. 

Lease/Site Details
If more than one lease/site, attach the following details for each lease/site

Block			
			
Section		Unit (if applicable)		
		
Suburb		
		
District		
			
Street Number			
		
Street Name		
			
Postcode			

Applicant Details Please Print

Surname			First Name		
		
Company Name		
		
Position held in company			Australian Company Number (ACN)		
		
Postal Address		
		
Suburb			State			Postcode		
				
Phone Number Business Hours			Mobile		
		
EMAIL ADDRESS		

Lessee (Property Owners) Details Please Print

1st Lessee’s Details

Surname	
		First Name		
		
Company Name	

Position held in company			Australian Company Number (ACN)		
		
Postal Address	

Suburb	
		State			Postcode		
				
Phone Number Business Hours			Mobile		
		
EMAIL ADDRESS	

All lessees must sign authorising the lodgement of this application. In doing so the lessee gives authority to the applicant to negotiate any dealings in relation to the application through to its determination.  If there are more than two lessees please ensure that the details and authorisation are attached to the application.

Lessee (Property Owners) Details continued 

2nd Lessee’s Details 

Surname	
		First Name		
		
Company Name	

Position held in company			Australian Company Number (ACN)		
		
Postal Address	

Suburb	
		State			Postcode		
				
Phone Number Business Hours			Mobile		
		
EMAIL ADDRESS	

Required Document

Have you provided an estimate of the lease variation charge? 
The estimate must identify the applicable schedule(s), the rate applied and the estimated charge.	•	YES
•	NO	

Applicant and Lessee Declaration
I/we the undersigned, hereby apply to have the change of use charge assessed under section 276D of the Planning and Development Act 2007;
I/we declare that this application is accompanied by the required document addresses the relevant requirements of the Act;
I/we understand that this application will be electronically scanned; 
I/we the undersigned (lessee(s)) appoint the applicant whose signature appears below to act on my/our behalf in relation to this application. This authorises the applicant to liaise with the Planning and Land Authority when required, alter, amend or provide further information as necessary and receive any communications relating to this application.
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, organisation or Government agency: -
I/we the undersigned, declare I/we have the appropriate delegation or authority to sign on behalf of the company, organisation or Government agency.

Applicant’s Signature	
	Date		
				
1st Lessee’s Signature	
	Date		
				
2nd Lessee’s Signature	
	Date		

Privacy Notice
The personal information on this form is being collected to enable processing of your application. Collection of personal information is authorised by Chapters 7, 8 and 9 of the Planning and Development Act 2007. The information that you provide may be disclosed to the ACT Revenue Office, the Australian Valuation Office and the Registrar-General’s Office. The information may be accessed by other government agencies, ACTEWAGL, ACTEW Corporation and other commercial organisations interested in development and building information. 
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