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

APPLICATION TO NOTE CHANGE OF NAME ON CERTIFICATE OF TITLE	
Form 009 - CN	

	Land Titles Act 1925	

IMPORTANT INFORMATION
This form is to be used to lodge an application to note change of name on certificate of title 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 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
	
LODGEMENT AND CONTACT INFORMATION	

Email:
actlandtitles@act.gov.au
General Enquiries: 
(02) 6207 3000 
	
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 NOTE CHANGE OF NAME ON CERTIFICATE OF TITLE	
Form 009 - CN	

	Land Titles Act 1925	

LODGING PARTY DETAILS	
Name	Postal Address	Contact Telephone Number	
     	     	     	

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

CURRENT FULL NAME AS IT APPEARS ON CERTIFICATE OF TITLE (Surname Last)	
     	

NEW FULL NAME AS IT IS TO APPEAR ON CERTIFICATE OF TITLE (Surname Last)	
     	

REASON FOR CHANGE OF NAME (eg Marriage)	EVIDENCE (Registration details of Marriage Certificate, Change of Name Certificate etc including State/Country of Issue)	
     	     	

PROPRIETOR/S EXECUTION	

Print full name of Proprietor

     

Signature of Proprietor

Dated -      	
Print full name and address of witness 

     

Signature of witness

Dated -      	

STATUTORY DECLARATION	

I,                                                                        of                                                                                                         , 

                                                                                                                 (occupation) declare that I am one and the same person as

                                                                                                        , the registered proprietor (or one of the registered proprietors) in

Crown Lease / Certificate of Title Volume                      Folio                     .  I have changed my name by (marriage, registration of 

change of name, divorce etc)                                                                        .

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.

STATUTORY 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 / Annexures		
Registration date		Production number		
PRIMARY EVIDENCE	
Birth Certificate		Passport		
Citizenship				
SECONDARY EVIDENCE	
Drivers Licence		Medicare 		
Pension Card		Tax File