This form should be completed when the owner/lessee of land in a registered community title scheme proposes to sell or dispose of land that is to be developed or further developed in accordance with the community title scheme.

Lot(s) in Community Title Scheme to be assigned Please Print

Block/s	
		Section			Suburb		
		
Street Address	

Community Title Scheme Number	

Lessee (owners) details Please Print

1st Lessee details
Surname	
		First Name		
		
Company Name	

              Postal Address	

Suburb	
		State			Postcode		
				
Phone Number Business Hours			Mobile		
		
Email Address

2nd Lessee details
Surname	
		First Name		
		
Company Name	

              Postal Address	

Suburb	
		State			Postcode		
				
Phone Number Business Hours			Mobile		
		
Email Address

Buyers details Please Print

1st buyers details

Surname	
		First Name		
		
Company Name	

Postal Address	

Suburb	
		State			Postcode		
				
Phone Number Business Hours			Mobile		
		
Email Address	

2nd buyers details

Surname	
		First Name		
		
Company Name	

Postal Address	

Suburb	
		State			Postcode		
				
Phone Number Business Hours			Mobile		
		
Email Address	

Conflict of Interest Declaration

Does the lessee or buyer have any association with EPD staff?	•	NO
•	YES	
If YES - please provide details:	

NOTE: There are penalties for deliberately giving false and misleading information. The Planning and Land Authority or Minister may revoke an approval if satisfied that the approval was obtained by fraud or misrepresentation.

Lessees Declaration

I/we the undersigned, hereby apply to assign land under a registered community title scheme on the land specified in this application; and

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 or organization:

I/we the undersigned, declare I/we have the appropriate delegation or authority to sign on behalf of the company or organization.

1st Lessee’s Signature	
	Date		

2nd Lessee’s Signature	
	Date		

Buyers Declaration

I/we the undersign, hereby undertake to develop the land in accordance with the registered community title scheme on the land specified in this application; 

I/we understand that payment of a security may be required to be paid; and

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 or organization:

I/we the undersigned, declare I/we have the appropriate delegation or authority to sign on behalf of the company or organization.

1stBuyer’s Signature	
	Date		

2nd Buyer’s  Signature	
	Date		

Privacy Notice
The personal information on this form is provided to the Environment and Planning Directorate (EPD) to enable the processing of your application. The collection of personal information is authorised by the Community Title Act 2001.  If all or some of the personal information is not collected EPD cannot process your application. The personal information you provide may be disclosed to Australian Bureau of Statistics, ACT Revenue Office, the Registrar General’s Office and other Government agencies with a direct interest in the Unit Title process.  The information may also be disclosed where authorised by law or court order, or where the Directorate reasonably believes that the use or disclosure of the information is reasonably necessary for enforcement-related activities conducted by, or on behalf of, an enforcement body. 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.planning@act.gov.au

Contact Details:
Environment and Planning Directorate
Customer Service Centres 
GPO Box 158, Canberra City 2601 
8 Darling Street Mitchell, ACT 2911
16 Challis Street Dickson ACT 2602
Business Hours: 8.30am to 4.30pm weekdays (excluding Public Holidays
Phone: (02) 6207 1923	TTY: (02) 6207 2622
Email: epdcustomerservices@act.gov.au	Website: www.planning@act.gov.au