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	

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 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 provided to the Environment and Planning Directorate (EPD) to enable the processing of your application. The collection of personal information is authorised by the Planning and Development Act 2007.  If all or some of the personal information is not collected EPD cannot process your application. 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. The personal information you provide may be disclosed to Australian Bureau of Statistics, ACT Revenue Office, the Registrar General’s Office, ACTEW Corporation, ActewAGL, Territory and Municipal Services Directorate and other Government agencies with a direct interest in the development assessment 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