Lease/Site Details Please Print

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

Block/s	
		Section			Suburb		
		
District	

Street Address	

Details of Development Approval to be Surrendered Please Print

DA Number:
			Date Approval Granted:		

Description of Development Approval:

Reason(s) for Surrender:

(Please attach additional documentation if insufficient space)
Applicant Details Please Print

Surname	
		First Name		
		
Company Name	

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/Business Number (ACN/ABN)		
		
Postal Address	

Phone Number Business Hours			Mobile		
		
EMAIL ADDRESS	

2nd Lessee’s Details 

Surname	
		First Name		
		
Company Name	

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

Phone Number Business Hours			Mobile		
		
EMAIL ADDRESS	

All lessees must sign authorising the surrender of this development approval. 

Commencement of Development 

Has the development commenced?	•	YES	•	NO 	

If development has commenced:

Provide details of what portion of the development has been carried out in compliance with any conditions of approval, or any agreement with the Planning and Land Authority that is relevant to that part of the development.

__________________________________________________________________________________________________________________

Will the surrender of the development approval have an adverse impact on any third party or the locality?	•	YES	•	NO	

Please provide details:

Applicant/Lessee/s Declaration

I/we declare that all the information given on this form is true and complete.  In accordance with provisions of the Planning & Development Act 2007, I/we surrender the existing development approval or part thereof as specified in this application.  It is acknowledged that by surrendering the right, it cannot be re-enacted or re-used by the current or future owners of the subject property.

Applicant Signature (s)	
	Date		
				
Lessee 1 Signature (s)	
	Date		
				
Lessee 2 Signature (s)	
	Date		

If there are more than two lessees please ensure that the signatures of ALL lessees
 are provided with this application.

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 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. The Planning and Development Act 2007 requires the details of applications, decisions and orders to be kept on a register and made available for public inspection. Information and documentation relevant to a development application may be made available via the Internet.

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