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LESSEE(s) DECLARATION

if more than two lessees please provide details of each additional lessee on a separate sheet



I/we declare that I am/we are the lessee(s) of the land described above;



I/we have been made aware of the declaration clauses in the DA or Application for Reconsideration form; and



I/we declare that all the information given on this form is true and complete.

Lessee’s

Date

Signature

Lessee’s

Date

Signature

APPLICANT DECLARATION



I declare that I am the person authorised to sign/sign on behalf of the company described in this form



I declare that all the information given on this form and its attachments are true and complete;

Applicant

Company

Name

Signature

Date

LAND CUSTODIAN AUTHORISATION



I/we declare that I am/we are the land custodian(s) of the public land or unleased land as described above;



I/we authorise the applicant to obtain information in relation to this site through the pre‐application process and make an

application for development approval.

Delegate

Agency Name

Name

Signature

Date

Delegate

Agency Name

Name

Signature

Date

THIS AUTHORISATION DOES NOT CONSTITUTE AN APPROVAL IN PRINCIPLE OR OTHERWISE BY THE LAND CUSTODIAN

IN RELATION TO THE PROPOSED DEVELOPMENT.

Privacy Notice

The personal information on this form is provided to the Environment, Planning and Sustainable Development Directorate (EPD) to enable the processing of

your application. The collection of personal information is authorised by the Planning and Development Act 2007. If all or some of the personal information

is not collected EPSDD cannot process your application. The Planning and Development Act 2007 requires the details of applications, decisions and orders to

be kept on a register and made available for public inspection. Information and documentation relevant to a development application may be made

available via the Internet. The personal information you provide may be disclosed to Australian Bureau of Statistics, ACT Revenue Office, the Registrar

General’s Office, ACTEW Corporation, ActewAGL, Territory and Municipal Services Directorate and other Government agencies with a direct interest in the

development assessment process. The information may also be disclosed where authorised by law or court order, or where the Directorate reasonably

believes that the use or disclosure of the information is reasonably necessary for enforcement‐related activities conducted by, or on behalf of, an

enforcement body. EPSDD’s Information Privacy Policy contains information about how you may access or seek to correct your personal information held by

EPSDD, and how you may complain about an alleged breach of the Territory Privacy Principles. The EPSDD Information Privacy Policy can be found at

Contact Details:

Environment, Planning and Sustainable Development Directorate

Business Hours: 8.30am to 4.30pm weekdays (excluding Public Holidays)

Customer Service Centres

Phone: (02) 6207 1923

GPO Box 158, Canberra City 2601

Email: epdcustomerservices@act.gov.au

16 Challis Street Dickson ACT 2602

Website:

FORM 4 ‐ LETTER OF AUTHORISATION

Authorised by the ACT Parliamentary Counsel—also accessible at