This cover sheet is to be attached to the other documentation required under the Unit Titles Regulation 2001 or any statute or statutory provision that amends, extends, consolidates or replaces this regulation.

LEASE/SITE DETAILS:

Block(s)	Section	Suburb/District

Street Address:

UNIT TITLES WORKS ASSESSOR DETAILS:

Name

Company Name	Australian Company Number (A.C.N.)

Street Address

Telephone Number	Fax Number

Email Address – Please Print

Date Report Prepared	Date Report Given to Applicant

Applicant’s Name

Signature of Assessor	Date	License no.