ACT HERITAGE ACT
					AF2014-108
For ACT Heritage Use Only	
Date received		
File No.		
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Date to Council		
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Accepted?		

ACT HERITAGE ACT—
APPLICATION FOR APPROVAL OF A STATEMENT OF HERITAGE EFFECT
Heritage Act 2004, s61G

The ACT Heritage Act 2004 (the Act) establishes a system for the recognition, registration and conservation of places and objects having heritage significance and for all Aboriginal places and objects. 
Under sections 74 and 75 of the Act, a person commits an offence if the person engages in conduct that diminishes the heritage significance of a place or object or if the person engages in conduct that causes damage to an Aboriginal place or object.

However, under s76 of the Act, such conduct is not an offence if carried out in accordance with any of the following:
•	A heritage guideline;
•	A heritage direction;
•	A heritage agreement;
•	A conservation management plan approved by the Council;
•	An excavation permit;
•	A Statement of Heritage Effect approved by the Council;
•	Development approval under the Planning and Development Act 2007 chapter 7; or
•	If the person is a government officer exercising a function for the Heritage Act or another Territory law or engaging in authorised conduct.

This form may be used to seek the Council’s approval of a Statement of Heritage Effect (SHE) for the purposes of being able to engage in certain activity which is exempt from the offence provisions.

A person or entity proposing to undertake activity that is likely to diminish the heritage significance of a place or object, or likely to damage an Aboriginal place or object, may make an application for approval of an SHE. No fee is payable for seeking approval of an SHE. An application will not be accepted unless signed and dated.

The ACT Heritage Council will notify you as soon as possible about its acceptance or dismissal of this application. An SHE may be approved with conditions.

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 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 

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)

_______________________________________________________________________________________________
Description of place’s boundary or objects components

For Aboriginal places, natural or rural locations: 
attach a sketch map, map references and/or GPS coordinates.

Exact locations of Aboriginal places are treated as restricted information and should not be divulged to other
parties. 

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 STATEMENT OF HERITAGE EFFECT 
You must attach to this application a copy of the Statement of Heritage Effect that – 

Describes the place or object;
Provides details about the proposed activity;
Provides reasons for the proposed activity, including the extent and duration of the activity;
Describes the likely effect of the proposed activity on the place or object including the effects that may diminish the heritage significance of, or damage to, the heritage place or object or Aboriginal place or object;
Identifies measures to be adopted during the activity to reduce the risk of diminishing heritage significance or causing damage to an Aboriginal place or object;
Identifies whether there are other reasonably practicable ways of carrying out the activity; and
Provides details about the heritage significance of the place or object.

List all attachments enclosed:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

04. 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 limited access to restricted information. 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. 

05 AUTHORISATION 

I wish to make application for the Heritage Council to approve the attached Statement of Heritage Effect (SHE).  

The information provided in the SHE is accurate to the best of my knowledge.

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

Signed: ______________________________

Date: _________________