33 Hyde Street • Bellingen • NSW
E: council@bel ingen.nsw.gov.au
P.O. Box 117 Bellingen NSW 2454
T: (02) 6655 7300 F: (02) 6655 2310
www.bellingen.nsw.gov.au
ABN: 26 066 993 265
Please email completed form to xxxxxxx@xxxxxxxxx.xxx.xxx.xx, or post or lodge at Bellingen Shire Council.
Government Information (Public Access) Act 2009
ACCESS APPLICATION - FORMAL
Please complete this form to apply for formal access and/or disclosure of open access records under
the Government Information (Public Access) Act 2009 (GIPA Act). If you need help in filling out this
form, please contact the Right to Information Officer at Council.
1. Your Details
Company Name:
...............................................................................................................................
(If legal representative)
Surname:
..................................................................................
Title: Mr / Mrs / Ms / Dr
Other names:
............................................................................................................................
Postal address:
..........................................................................................
Postcode: .............
Day-time telephone: .....................................................
Facsimile: ....................................................
Email:
.............................................................................................................................
I agree to receive correspondence at the above email address.
The questions below are optional and the information will only be used for the purposes of providing better service.
Aboriginal or Torres Strait Islander:
Yes / No (circle one)
Do you have special needs for assistance with this application: .......................................................
........………………………………………………………………………………………………………………….
.........................................................................................................................................................................................................
2. Proof of Identity
Only required when you are requesting information on your own behalf.
When seeking access to personal information, you must provide proof of identity in the form of a
certified copy of any one of the following documents:
Australian driver’s licence
Current Australian passport
with photograph, signature and current address
Other proof of signature and current address details
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Government Information (Public Access) Act 2009
FORMAL ACCESS APPLICATION FORM
3. Government Information
If requesting information about a property:
Street Number: ........... Street Name: ............................................................. Location: ..........................
(If known) Lot Number: ........... Section: ............ DP / SP Number: ...................................
Application No/s if known: ............................................................................................................................
Please describe the information you would like to access in enough detail to allow the Council to
identify it.
Note: If you do not give enough details about the information, Council may refuse to process your application
...................................................................................................................................................................
...................................................................................................................................................................
..................................................................................................................................................................
..................................................................................................................................................................
Are you seeking personal information?
Yes / No (circle one)
Have you applied at any time to another agency for substantially the same information?
Yes / No (circle one) If yes, please provide the name of the other agency
..........................................................................................................................................................
4. Form of Access
How do you wish to access the information?
Inspect the document(s)
Email a copy of the document(s)
Access in another way (please specify) ......................................................................................
..........................................................................................................................................................
5. Application Fee
I attach payment of the
$30 application fee by cash / cheque / pay over phone via credit card.
(Note: please do NOT send cash by post. Payment must be made to the agency you are requesting information from)
6. Third Party Consultation
Under section 54 of the GIPA Act, if the information you are requesting contains information about
another person, business or agency, the agency may be required to consult with third parties before
deciding your application. The purpose of this consultation is for the agency to determine whether
the third party has an objection to disclosure of some or all of the information being requested. Do
you consent to your identity as an applicant being disclosed to the involved third party?
Yes /
No (circle one)
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Government Information (Public Access) Act 2009
FORMAL ACCESS APPLICATION FORM
7. Disclosure Log
If the information sought is released to you and the IPC consider it may be of interest to other members
of the public, details about your application may be recorded in the agency’s ‘disclosure log’. This is
published on the IPC’s website. If you object to this, we must first decide if you are entitled to object and
if so, whether the objection outweighs the general public interest in including this information in the
disclosure log.
You can only object to the inclusion of information on an agency’s disclosure log for one or more of the
following grounds:
• The information includes personal information about you (or a deceased person for whom you
are the personal representative)
• The information concerns your business, commercial, professional or financial interests
• The information concerns research that has been, or is being, or is intended to be, carried out by
or on your behalf
• The information concerns the affairs of a government of the Commonwealth or another State
(and you are entitled to act on behalf of that government agency).
Do you object to this?
Yes /
No (circle one)
Please note: if an agency decides to include information in its disclosure log despite your objection, you
can seek a review of this decision.
8. Discount in Processing Charges
You may be asked to pay a charge for processing the application ($30/hour). Some applicants may
be entitled to a 50% reduction in their processing charges. If you wish to apply for a discount,
please indicate the reason:
Financial hardship – please attach supporting documentation (eg a pension or Centrelink
card)
AND / OR Special benefit to the public – please specify why below:
..........................................................................................................................................................
..........................................................................................................................................................
Your signature: ...................................................................................
Date: .........................................
General information about the GIPA Act is available by calling the Information and Privacy Commission on
1800 472 679 or visit the IPC’s website: www.ipc.nsw.gov.au
Office Use Only
Date application received: .............................................. Receipt No: ..................................
File reference: ..................................................................................................
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