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

APPLICATION TO NOTE CHANGE OF NAME
ON AN INSTRUMENT		
Form 010 - CNI	

	Land Titles Act 1925		

IMPORTANT INFORMATION

This form is to be used to lodge an application to note change of name on an instrument 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.

LODGEMENT AND CONTACT INFORMATION
	
Website: 	In Person:	
www.accesscanberra.act.gov.au 	Environment, Planning and Land Shop Front	
General enquiries: 	Ground Floor South, Dame Pattie Menzies House, 16 Challis Street Dickson	
13 22 81	Opening hours – Monday to Friday 8:30am to 4:30pm

INSTRUCTIONS FOR COMPLETION
•	The certificate of title or production of title consenting to the registration of this document is required for lodgement.
•	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.
•	Ensure all required documents are attached.  If there is insufficient space in any panel, please use an Annexure Sheet.

REQUIRED DOCUMENTS
•	The certificate of title or production of title consenting to the registration of this document is required for lodgement.
•	Evidence of how the name was changed eg: Marriage Certificate (Ceremonial Certificate is not acceptable) or Change of Name Certificate
•	One form of Primary Identification - Original or Certified Copy of Birth Certificate, Citizenship Certificate or Passport
•	One form of Secondary Identification – Original or Certified Copy of Drivers Licence, Medicare Card, Pension Card or Tax File Number Declaration issued by the Australian Taxation Office

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

APPLICATION TO NOTE CHANGE OF NAME
ON AN INSTRUMENT	
Form 010 - CNI	

	Land Titles Act 1925	
LODGING PARTY DETAILS	
Name	Email Address	Contact Telephone Number	
     	     	     	

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

REGISTERED DEALING NUMBER	TYPE OF DEALING (Sublease, Caveat, Mortgage)	
     	     	

NAME AS IT CURRENTLY APPEARS ON INSTRUMENT	
     	

NEW NAME (Full Name - Surname Last)	
     	

STATUTORY DECLARATION	

I,                                                                      (name) of                                                                                                         (address) , 

                                                                     (occupation) am the same person as                                                                                                       the Sublessee/Mortgagee/Caveator in dealing number                      registered on Crown Lease/Certificate of Title 
Volume                      Folio                     .  I changed my name on                      (date) by marriage/registered change of name 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.	

Declared at                                                                             on

the                        day of                                                        20

Signature of person making the declaration

	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)

     

Signature of person before whom the declaration is made

	
EVIDENCE OF CHANGE OF NAME	
Marriage Certificate	Place of Issue	Certificate Number		
Change of Name Certificate	Place of Issue	Certificate Number		
PRIMARY EVIDENCE	
Birth Certificate		Passport		
Citizenship				
SECONDARY EVIDENCE	
Drivers Licence		Medicare 		
Pension Card		Tax File 		

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