ACT HERITAGE REGISTER
					AF2014-104
For ACT Heritage Use Only	
Date received		
File No.		
Database ID		
Date to Council		
Decision date		
Accepted?		

ACT HERITAGE REGISTER—
CANCELLATION PROPOSAL
Heritage Act 2004, s43

The ACT Heritage Register contains details of places and objects of significance to the ACT.

This form is used to make an application proposing that a place or object (or part thereof) registered under the Heritage Act 2004 cease to be registered. 

Any person can request cancellation (or part thereof) of a registered place or object. 

In making this application, you are asked to identify the loss of heritage significance of the place or object and provide supporting evidence.

Each cancellation proposal will be publicly notified as well as being provided to each interested person as identified under the Heritage Act 2004. A four week period of public consultation will occur.

Any mistakes or omissions in a heritage register entry do not require the use of this form and can be reported directly to ACT Heritage on 13 22 81 or by email to heritage@act.gov.au. 

The ACT Heritage Council will notify you as soon as possible about its acceptance or dismissal of this proposal, and progress of associated processes and decisions. The Council may dismiss the proposal if the Council is satisfied on reasonable grounds that the proposal is frivolous, vexatious, misconceived, lacking in substance or not made honestly; or the Council has previously decided not to cancel the registration of the place or object and is satisfied that the proposal shows no substantial new ground for cancellation.

No fee is payable for the request to cancel a registration.

DO YOU REQUIRE MORE INFORMATION OR NEED HELP?
If you need help completing this form, contact ACT Heritage on 13 22 81 or 
email heritage@act.gov.au. Incomplete or inadequate forms will be returned with feedback.

More information about the ACT Heritage Council, the Heritage Register and the heritage registration and cancellation process is available on the ACT Heritage website at www.environment.act.gov.au/heritage 
or by contacting ACT Heritage on 13 22 81 or by email at heritage@act.gov.au. 

LODGING YOUR FORM
Please send this form
o by mail to: The ACT Heritage Council, PO Box 158, Canberra  ACT 2601; 
o by hand to: ACT Heritage, Dame Pattie Menzies House, 16 Challis Street, Dickson ACT
o	 by email to: heritage@act.gov.au 

A cancellation proposal will not be accepted unless signed and dated.

01 DETAILS OF PLACE OR OBJECT

Place 		Object 

Type: 		natural 		Aboriginal 	 historic		other/combined

Name of place/object:	_________________________________________________________

Other names if any:	_________________________________________________________

Location:	________________________________________________________________
Address							Suburb

_______________________________________________________________________________________________
Block/Section/District/Division (If multiple addresses or blocks and sections, list all)

02 YOUR DETAILS

Name:		________________________________________________________________
Title		First Name			Surname

Organisation	________________________________________________________________
Organisation Name (if the organisation is the nominator)	Position

Postal Address:________________________________________________________________
Postal Address					State	Postcode

Telephone:	________________________________________________________________
Business Hours		After Hours		Mobile

		_______________________________________________________________________________
Email

Do you have any personal association with the place or object? 		yes 		no

If yes, how would describe yourself:

owner 		tenant 		neighbour

a person with traditional (Aboriginal) affiliation with the place or object

other _______________________________

03 CANCELLATION PROPOSAL 

Full cancellation of the Heritage register entry

Partial cancellation of the Heritage register entry
What features/area are proposed for cancellation?
         Please attach a map or list if needed and identify specific features which you believe no longer have heritage significance e.g. interiors, exterior elements, archaeological, landscape or natural features, or objects.
_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

04 LOSS OF HERITAGE SIGNIFICANCE 
Details of cancellation proposal (why is it no longer significant?)
You must address the heritage significance criteria identified in the Register Entry

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

05 FURTHER SUPPORTING INFORMATION
Additional attachments can also be provided

Provide any known details for the owner/s, unless   	 same as applicant for cancellation

Is the owner/s aware of the cancellation proposal? 	
no 	yes 	some are (indicate which if multiple owners)

Does the owner/s support the cancellation proposal? 
no 	yes 	some do (attach letter/s of support, if possible)

Does the owner consent to your providing their personal information?   	 no	yes

If yes, fill in the information below. If no, proceed to the next section

Current owner:	____________________________________________________________________
Name (attach additional details if multiple owners)

Address:	____________________________________________________________________
Postal or Street Address State Postcode

Telephone:	____________________________________________________________________
Business Hours	After Hours	Mobile

		_____________________________________________________________________________
Email

Please indicate if any of the following has changed in any substantial way since the Register Entry was
notified:

Physical condition: (covering key features and attach photographs)
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Damage or destruction that has reduced or diminished its significance:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Changes of use/ownership or other significant change:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Supporting Documentation: Please list any further documentation that will support this proposal,
e.g. engineering reports, arboricultural reports, heritage surveys, condition assessments, historic documents, maps or photos, written histories, oral histories, heritage assessment reports (include
author, date and name), site recording forms for Aboriginal places/objects (contact ACT Heritage for blank
forms).

Author/s or Source	Title/Description	Date	

			

List all attachments enclosed:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

06 AUTHORISATION 

I wish to have this registration cancelled, in whole or in part as indicated, in accordance with Part 7 of the Heritage Act 2004. 

The information provided here is accurate to the best of my knowledge and may be made publicly available for
the purpose of cancelling the registration of this place or object, unless otherwise indicated.

I understand that giving false or misleading information is a serious offence under the Criminal Code 2002.

07 PERSONAL INFORMATION DISCLOSURE STATEMENT

The personal information on this form is provided to the ACT Heritage Council and ACT Environment and Planning Directorate for the purpose of processing your application for cancellation of registration of a heritage place or object. If you do not provide your contact details, the Heritage Council will not be able to process your application. EPD’s Information Privacy Policy contains information about how you may access or seek to correct your personal information held by EPD, and how you may complain about an alleged breach of the Territory Privacy Principles. The EPD Information Privacy Policy can be found at www.act.gov.au/epd/information_privacy.

       By ticking this box I give my consent for my name/organisation to be disclosed as the applicant for this cancellation proposal. 

Signed: ______________________________

Date: _________________