This form is required to apply for a further Crown lease for land within the ACT either for the same term 
as the original lease or for an additional term.

Lease details please print

Block/s	
	Section 		Suburb		Unit No.		

Street Address	

Applicant details please print

Surname	
		First name		
		
Company name	

Postal address	

Phone number business hours			Mobile		
		
Email address

Lessee (property owners) details please print

First lessee’s details

Surname	
		First name		
		
Company name	

Position held in company			Australian Company Number (ACN)		
		
Street address
(not PO Box)	

Phone number business hours			Mobile		
		
Email address	

Second lessee’s details

Surname	
		First name		
		
Company name	

Position held in company			Australian Company Number (ACN)		
		
Street  address
(not PO Box)	

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.
		
Summary Information please print

Type of lease the applicant is seeking:

	Non-Rural

•	Commercial	•	Residential	•	Industrial	•	Unit Title	•	Other	

	Number of Years

•	99 Years	•	Same as Original Term	•	Other (specify)_______________________________	

OR

RURAL (lease to accord with current policies)

	Type of lease applicant is seeking

•	Long Term – 21-99 years	•	Short Term – less than 21 years	

	Nominate Form of Payment

•	Lump Sum	•	Partial Lump Sum plus 30 years for remainder	•	30 year payout	

Please specify the number of dwellings on site ______________________			

Does the purpose clause of your lease allow for agistment?	•	YES	•	NO	

If Yes - how many horses do you agist?  _______________________

Conflict of interest declaration

Does the applicant, lessee or buyer have any association with EPD staff?          	•	YES	•	NO	
If YES - please provide details:	

NOTE: There are penalties for deliberately giving false and misleading information.  The Planning and Land Authority or Planning Minister may revoke an approval if satisfied that the approval was obtained by fraud or misrepresentation.

Applicant’s & Lessee’s declaration

I/we the undersigned, hereby apply for the grant of a Further Crown lease on the land specified in this application.

I/we understand that the requirements set out in this form are a minimum only and that additional information may be requested during processing.

I/we the undersign appoint the applicant whose signature appears below to act on my/our behalf in relation to this application for the grant of a Further Crown lease.  This authorises the applicant to pay all application fees and liaise with EPD when required, alter, amend or provide further information as necessary and receive any communications relating to this application for the grant of a Further Crown lease.

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

I/we acknowledge that the EPD intends to make a decision on whether the Crown lease is concessional or not.

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 organization.

Applicant signature (s)	
	Date		
				
First lessee’s signature	
	Date		
				
Second 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 Planning and Development Act 2007.  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 lease transfer 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