Lodgment No:		
Conveyance Lodgment Form
Complete this form when lodging documents relating to transfers of land, a Crown lease, Land Rent transactions, Residential Surrender & Re-grants, or a land use entitlement in the ACT. Please PRINT CLEARLY and complete all unshaded areas.

CLIENT NAME:		
CLIENT ACCOUNT NUMBER:		
CONTACT NAME:		
ADDRESS:		
TELEPHONE:		
EMAIL: 		
Please indicate using the tick boxes below if this transaction is connected with any of the following schemes:
Deferred Duty 	Home Buyers Concession	Pensioner Duty Concession	Over 60’s Home Bonus	
Section 1 – transaction details	
Date of Agreement/Transfer (First execution):		
Name of transferor/seller	Name of transferee/buyer	

Lease purpose clause:	Residential	Commercial	Land Rent	
Dutiable value	Suburb	Section 	Block	Unit	
$					
Land and Improvements:	         Vacant land	         Completed building	        Incomplete building	
Form of Tenancy (Tick one of the following)	
         Sole proprietor  	         Joint Tenants	         Tenants in common in equal shares	
          Tenants in common in the following shares.  State proprietors’ names and shares in full below:	
DOCUMENTS LODGED AT A LATER DATE – Is this document being lodged for stamping at a later date than the original dutiable transaction document was lodged? (Section 17, Duties Act 1999)	        No	Yes - what is the lodgment number for the original dutiable transaction?
LODGMENT REFERENCE NUMBER:	
NEW CROWN LEASE – Is this a new Crown lease granted by the Territory, the Commonwealth or the Federal Capital Commission?	        No	Yes 	
SURRENDER AND RE-GRANTS – Is this a new Crown lease granted on the surrender of a development lease? 	        No	Yes – attach a letter from the granting authority	
TRUSTS – Does the document lodged involve a declaration of trust over dutiable property, change of trustee or variation of trust?	        No	Yes – attach the declaration of trust or other relevant trust documents.	
AGGREGATION – Is the transaction listed above an arrangement which involves two or more separate items of dutiable property, which occurred within 12 months of each other, and the transferee’s/buyer’s are associated people?	        No	Yes - attach a statement setting out the particulars of the transactions (date, property values, property identifiers)	

Section 2 – RESIDENTIAL LAND RENT TRANSACTIONS	
Is this transaction a land rent lease payout? 	   No	    Yes	
Is this a land rent lease transfer with improvements? 	        No	    Yes - provide the value of the land and improvements	Land Value $	
			Improvements Value $	
SECTION 3 – RESIDENTIAL OFF THE PLAN AGREEMENT	
Is this transaction an Off the Plan Agreement?
	No - Go to section 4	Yes - Complete ONE of the following 5 statements in this section	
1.	The agreement was completed on:	Date 	
2.	All, or any part of the tranferees interest under the agreement was assigned:	Date	
3.	The period of 12 months, beginning from the date of the agreement expired on:	Date	
4.	A Certificate of Occupancy for the building to which the agreement relates was issued under the relevant ACT legislation: 
(Attach Copy of Certificate of Occupancy)	Date	
5.	I wish to lodge the documents on a date prior to any of the above events occurring:	Date	
section 4 – answer ALL OF the following 5 questions	
1.	
1.	Is any Transferor of the property above related to or associated with any Transferee?	       No	Yes - attach a property valuation report by a certified valuer for stamp duty purposes	
2.	Is the property being transferred for less than its dutiable value?	       No	Yes - attach a property valuation report by a certified valuer for stamp duty purposes	
3.	Is the transferee acquiring an interest in a landholder under chapter 3 of the Duties Act 1999? (Unlisted Shares, Units and Interests)	       No	Yes - attach a completed Landholder Transfer of Unlisted Shares, Units and Interest Lodgment Form	
4.	Did the vendor act without the use of a Real Estate Agent/Auctioneer to sell this property?	       No	Yes	If you answered YES to BOTH questions 4 and 5 attach a property valuation report by a certified valuer for stamp duty purposes	
5.	Is the same legal firm acting for both parties? 	       No	Yes		
A valuation report is not required if the transfer relates to a deceased estate, Family Court Order/Financial Agreement under the Family Law Act 1975 (Cth), Domestic Relationship/Termination Agreements under the Domestic Relationships Act 1994, or the transfer of an interest in a principal place of residence to a spouse, unless requested by this office.	
section 5 – DECLARATION
DECLARATION: I …………………………………………………...................................... of ……………………………………………………………………… 
being the transferee/transferee’s authorised agent [delete whichever is not applicable] declare that the above information is, to the best of my knowledge, true and correct and in conformity with the agreement between the parties. I also acknowledge that I have read and understand the Privacy Statement.	
SIGNED:	DATE:	
GIVING FALSE OR MISLEADING INFORMATION IS A SERIOUS OFFENCE (Criminal Code 2002)	
Privacy Statement - All information collected by the ACT Revenue Office is protected by secrecy provisions in Acts administered by the Office and only used for the purposes of those Acts. In addition, personal information provided to the ACT Revenue Office is protected by the Information Privacy Act 2014. Information (including personal information) is not disclosed to any third party unless authorised by law or with the consent of the person involved.