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 being collected to enable processing of your application. Collection of personal information is authorised by Chapters 7, 8 and 9 of the Planning and Development Act 2007. The information that you provide may be disclosed to the ACT Revenue Office, the Australian Valuation Office and the Registrar-General’s Office. The information may be accessed by other government agencies, ACTEWAGL, ACTEW Corporation and other commercial organisations interested in development and building information. 
Contact Details:
Environment, Planning and Sustainable Development Directorate
Customer Service Centre
GPO Box 158, Canberra City 2601
16 Challis Street, Dickson ACT 2602
Business Hours: 8.30am to 4.30pm weekdays (excluding Public Holidays)
Phone: (02) 6207 1923
Email: epdcustomerservices@act.gov.au	Website: www.planning.act.gov.au