Lease/Site Details

If more than one lease/site, attach the following details for each lease/site
	
Block	

Section	
	Unit (if applicable)		
		
Suburb	

District	

Street Number	

Street Name	

Postcode			

Grounds on which Reconsideration is Sought (Please attach further information if space is insufficient)

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Applicant Details Please Print

Surname	
		First Name		
		
Company Name	

Position held in company			Australian Company Number (ACN)		
		
Postal Address	

Suburb	
		State			Postcode		
				
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 Number (ACN)		
		
Postal Address	

Suburb	
		State			Postcode		
				
Phone Number Business Hours			Mobile		
		
EMAIL ADDRESS	

All lessees must sign authorising the lodgement of this application. In doing so the lessee gives authority to the applicant to negotiate any dealings in relation to the application through to its determination.  If there are more than two lessees please ensure that the details and authorisation are attached to the application.

Lessee (Property Owners) Details continued 

2nd Lessee’s Details 

Surname	
		First Name		
		
Company Name	

Position held in company			Australian Company Number (ACN)		
		
Postal Address	

Suburb	
		State			Postcode		
				
Phone Number Business Hours			Mobile		
		
EMAIL ADDRESS	

Provision of Notice of Reconsidered Decision 

Unless otherwise specified your notice of reconsidered decision will be returned via email

•	POST TO ME		•	HOLD FOR COLLECTION	

Documentation Supporting Application

Have you provided an independent valuation prepared by a valuer as required by section 277D(4) of the Planning and Development Act 2007 that works out the amounts represented by V1 and V2  in section 277 of the Planning and Development Act?	•	YES
•	NO	
		
Has the independent valuation been prepared by an accredited valuer who was not involved in working out or advising on the original decision and has been agreed to by the commissioner for revenue? Please provide evidence confirming the valuer’s independence.	•	YES
•	NO	
		
If you have been provided with a working out statement by the Planning and Land Authority on behalf of the Commissioner for Revenue have you provided a copy of the statement? 	•	YES
•	NO	

Conflict of Interest Declaration

Does the applicant or lessee have any association with staff of the Environment and Sustainable Development Directorate?	•	NO
•	YES	
If YES please provide details:	

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Applicant and Lessee Declaration

I/we the undersigned, hereby apply for reconsideration of the lease variation charge under section 277C of the Planning and Development Act 2007 (the Act);

I/we declare that this application is accompanied by all of the required information or documents that address the relevant requirements of the Act;

I/we understand that this application will be electronically scanned; 

I/we the undersigned (lessee(s) appoint the applicant whose signature appears below to act on my/our behalf in relation to this application.  This authorises the applicant to pay all application fees, bonds and securities, liaise with the Environment and Sustainable Development Directorate when required, alter, amend or provide further information as necessary and receive any communications relating to this application.

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, organisation or Government agency: -
I/we the undersigned, declare I/we have the appropriate delegation or authority to sign on behalf of the company, organisation or Government agency.

Applicant’s Signature	
	Date		
				
1st Lessee’s Signature	
	Date		
				
2nd Lessee’s Signature	
	Date		

				
Privacy Notice
The personal information on this form is being collected to enable processing of your application. Collection of personal information is authorised by Chapters 7, 8 and 9 of the Planning and Development Act 2007. The information that you provide may be disclosed to the ACT Revenue Office, the Australian Valuation Office and the Registrar-General’s Office. The information may be accessed by other government agencies, ACTEWAGL, ACTEW Corporation and other commercial organisations interested in development and building information. 

Contact Details:
Environment and Sustainable Development Directorate
Customer Service Centre
GPO Box 158 Canberra City 2601
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: esddcustomerservices@act.gov.au	Website: www.environment.act.gov.au