Section 296 of the Planning and Development Act 2007 states that a lessee may apply to the Planning and Land Authority for a certificate of compliance. In applying for the certificate, please ensure that all provisions of your Crown lease have been complied with. A copy of the certificate of occupancy and use must be provided at the time of lodgement of this application.

Lease Details Please Print

Block	
	Section 		Suburb		Unit No.		

Street Address	

Applicant Details Please Print

Surname	
		First Name		
		
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		
		
Postal Address	

Suburb	
		State			Postcode		
				
Phone Number Business Hours			Mobile		
		
EMAIL ADDRESS	

2nd Lessee’s Details 
Surname	
		First Name		
		
Postal Address	

Suburb	
		State			Postcode		
				
Phone Number Business Hours			Mobile		
		
EMAIL ADDRESS	

Applicant and Lessee Declaration

I/we declare that all the information given on this form and its attachments is true and correct.

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 Signature (s)	
	Date		
				
1st Lessee’s Signature	
	Date		
				
2nd Lessee’s Signature	
	Date		
				
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.

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 and lease compliance 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.environment@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.environment@act.gov.au

Office Use Only

Date lodged  ----/----/----	•	C of O provided 	•	Lessee Details Checked (TARQUIN)	
				
Receiving officer: