LAND TITLES
OFFICE OF REGULATORY SERVICES
ACT  Justice and Community Safety Directorate

APPLICATION TO
NOTE RETIREMENT VILLAGE		
Form 112 - NRV	

	Land Titles Act 1925		

IMPORTANT INFORMATION
This form is to be used to lodge an application to note retirement village 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 Environment and Sustainable Development Directorate, the Chief Minister and Treasury Directorate, 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 should be lodged with this request, or arrangements should be made to have the title produced by the party who holds it.  However, this is not essential.  If not produced, the notification will be entered onto the Register for the land and the client copy of the title will be updated when next produced.
•	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. (No witness is required for this execution).
•	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’) - (No witness is required for this execution).
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’) - (No witness is required for this execution).

	LAND TITLES
OFFICE OF REGULATORY SERVICES
ACT  Justice and Community Safety Directorate

APPLICATION TO
NOTE RETIREMENT VILLAGE		
Form 112 - NRV	

	Land Titles Act 1925		

LODGING PARTY DETAILS	
Name	Postal Address	Contact Telephone Number	
     	     	     	

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

FULL NAME OF APPLICANT/OPERATOR (Surname Last)	
     	

ADDRESS FOR SERVICE OF NOTICE OF APPLICANT (including post code)	
     	

FULL NAME AND ADDRESS OF THE REGISTERED PROPRIETOR ON TITLE (Please provide these details if the Applicant and Registered Proprietor differs)	
     	

LAND COMPRISED FOR USE BY RETIREMENT VILLAGE	

Request to Note Retirement Village pursuant to Section 42 of the Retirement Villages Act 2012 for the following -

    The Whole of the Land

    Part of the land comprised above (specify part and attach plan) .....................................................................................

TRADING NAME (include Trading Name of Retirement Village if different to Applicant/Operator)	
     	

 
APPLICANT/OPERATOR’S EXECUTION	

Print full name of applicant / operator

     

Signature and/or common seal execution of applicant
	
Print full name and address of witness 

     

Signature of witness

OFFICE USE ONLY	
Lodged by		Certificate of title lodged		
Data entered by		Certificates attached to title		
Registered by		Attachments / Annexures		
Registration date		Production number