This form should be completed when applying to amend a development statement after approval and prior to registration.

Lease details please print

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

Block/s	
	Section 		Suburb		Units Plan Number		

Street Address	

Applicant Details Please Print

Surname	
		First Name		
		
Company Name	

              Postal Address	

Suburb	
		State			Postcode		
				
Phone Number Business Hours			Mobile		
		
Email Address

Lessee Details Please Print

1st Lessee Details

Surname	
		First Name		
		
Company Name	

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

Phone Number Business Hours			Mobile		
		
Email Address	

2nd Lessee Details

Surname	
		First Name		
		
Company Name	

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

Phone Number Business Hours			Mobile		
		
Email Address	

Description of Amendment to Development Statement Please Print

•	How the staged development is to be carried out	•	Internal boundaries between units or between units and the common property	
•	The schedule of unit entitlement	•	Other	

Description

Written Agreement of Each Person

Are there copies of the written agreement of each person with an interest in the block for the land specified in this application attached?	•	NO	•	YES	

Approved Plans

Are there copies of the approved plans for any internal unit or common property boundary changes for the land specified in this application attached?

	•	NO	•	YES	
Conflict of Interest Declaration

Does the applicant or lessee 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.

Applicant and Owners Corporation Declaration

I/we the undersigned, hereby apply for approval to amend a development statement prior to registration on the land specified in this application;

I/we declare that this application is accompanied by all of the required information or documents for it to be considered for approval;

I/we understand that the documentation provided will be considered to be the relevant documentation associated with this application;

I/we the undersigned appoint the applicant whose signature appears below to act on my/our behalf in relation to this application to amend a development statement prior to registration. This authorises the applicant to pay all application fees, bonds and securities, liaise with EPD when required, alter, amend or provide further information as necessary and receive any communications relating to this application to amend a development statement prior to registration;

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 organisation.

Applicant Signature (s)	
	Date		

1st Lessee’s Signature	
	Date		

2nd Lessee’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 Unit Titles 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 Land Rent 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