LAND TITLES
ACCESS CANBERRA
Chief Minister, Treasury and Economic Development Directorate

APPLICATION TO REGISTER A CHARGE
 OVER LAND IN A RETIREMENT VILLAGE	
Form 114 - CHR	

	Land Titles Act 1925	

IMPORTANT INFORMATION
This form is to be used to lodge an application to register a charge over land in a retirement village under the Land Titles Act 1925 (the Act).  You can access the Act at www.legislation.act.gov.au.  You may also obtain further information and forms at www.act.gov.au/accesscbr.
	
PRIVACY INFORMATION
The Act authorises the Registrar-General to collect the personal information required by this form for the purposes of issuing a registration under the Act.  The Registrar-General prevents any unreasonable intrusion into a person’s privacy in accordance with the Information Privacy Act 2014. The Registrar-General provides identifiable information to law enforcement and other Directorates that have legal authority to request information under prescribed circumstances.
These agencies may also use this information to prepare and sell property sales reports to commercial organisations concerned with the development, sale or marketing of land.
	
INSTRUCTIONS FOR COMPLETION
•	The certificate of title is not required for lodgement of this document.
•	All information should be typed or clearly printed.  If completing this form by hand please use a solid black pen only.  
•	This office will not accept lodgement of this form if it is not completed in full.
•	Any alteration to information provided on this form must be struck through with a black pen.  Substitute information must be clear and all parties must sign in the margin.  Do not use correction fluid or tape.
•	Execution by:
a)	A Natural Person – Should be witnessed by an adult person who is not a party to the document.
b)	Attorney – if this document is executed by an Attorney pursuant to a registered power of attorney, it must set out the full name of the attorney and the form of execution must indicate the source of his/her authority e.g. “AB by his/her attorney XY pursuant to Power of Attorney ACT Registration No…… of which he/she has no notice of revocation”.  (This execution requires a witness).
c)	Corporation – Section 127 of the Corporations Act provides that a company may now validly execute a document with or without using a Common Seal if the document is signed by:
i.	Two directors of the company;
ii.	A director and a secretary of the company; or
iii.	Where the company is a proprietary company and has a sole director who is also the sole company secretary, that director.  (This execution does not require a witness).
•	The following forms of execution are suggested –
a)	With A Common Seal
The common seal of ABC Pty Ltd/Ltd ACN…………………
was affixed in the presence of-
...................................(signature)	
...................................(director/secretary)*
(*repeat if necessary i.e. if two directors signing.  If signing as sole director and sole secretary, state ‘director/secretary’) – (This execution does not require a witness).
b)	Without A Common Seal
Signed by ABC Pty Ltd/Ltd ACN……………………
...................................(signature)	
...................................(director/secretary)*
(*repeat if necessary i.e. if two directors signing.  If signing as sole director and sole secretary, state ‘director/secretary’) – (This execution does not require a witness).
	
LODGEMENT AND CONTACT INFORMATION	

Website:
www.accesscanberra.act.gov.au 
	
In Person:
Environment, Planning and Land Shopfront
Ground Floor South, Dame Pattie Menzies House, 16 Challis Street, Dickson
Opening hours - Monday to Friday 8:30am to 4:30pm (excluding public holidays)	

	LAND TITLES
ACCESS CANBERRA
Chief Minister, Treasury and Economic Development Directorate

APPLICATION TO REGISTER A CHARGE
 OVER LAND IN A RETIREMENT VILLAGE	
Form 114 - CHR	

	Land Titles Act 1925	

LODGING PARTY DETAILS	
Name	Postal Address	Contact Telephone Number	
     	     	     	

TITLE AND LAND DETAILS	
Volume & Folio	District/Division	Section	Block	Unit	
     	     	     	     	     	

RESIDENT UNDER CONTRACT WITHIN A RETIREMENT VILLAGE (who is not a registered proprietor)
 (Surname Last) (ACN required for all companies)	
     	

OPERATOR OF RETIREMENT VILLAGE / CHARGEE FULL NAME AND ADDRESS (Surname Last) (ACN required for all companies)	
     	

DETAILS OF STATUTORY CHARGE TO BE REGISTERED	
     	

EXECUTION 	

Print full name of the applicant / chargee

     

Signature or common seal of applicant / chargee

Dated -      	
Print full name and address of witness 

     

Signature of witness

Dated -      	

DATE	
     	

STATUTORY DECLARATION	

I,                                                                           of                                                                                                       , 

                                                                     (occupation)

I am the applicant / I act for the applicant in the capacity of (please state) –      

I solemnly and sincerely declare that the premises described in the land details on the front of this form are part of a residential premises in relation to a retirement village contract between       and       dated      .

I also declare that the charge created is over land where the resident under contract is not one of the following –
a.	the registered proprietor of land in the retirement village;
b.	the owner of a unit in a units plan in the retirement village;
c.	the owner of a lot in a community title scheme in the retirement village;
d.	a person who owns shares in a company title scheme that give rise to a residence right in relation to residential premises in the retirement village; or
e.	a registered long-term sublessee.

And I make this solemn declaration by virtue of the Statutory Declarations Act 1959, and subject to the penalties provided by that Act for the making of false declarations, conscientiously believing the statements contain in this declaration to be true in every particular.
	
STUATUTORY DECLARATION EXECUTION	

Declared at                                                                             on

the                        day of                                                        20

Signature of person making the declaration		Signature of person before whom the declaration is made

Full name, qualification* and address of person before whom the declaration is made (in printed letters) (*Must be authorised under the Statutory Declarations Act 1959)	

OFFICE USE ONLY	
Lodged by		Certificate of title lodged		
Data entered by		Certificates attached to title		
Registered by		Attachments / Annexure		
Registration date		Production number