Formal request to access information

Government Information (Public Access) Act 2009
Use this form to ask for access to information that may be commercially or
legally sensitive, personal or related to security.
Summary
This form
1  Your details
2  Proof of identity (only needed if you are asking for your personal information)
3  Information description
4  Fees and charges
5  Your right to access information
Your declaration
 The information provided on this form is true, complete and correct.
 I agree to the release of my name to any other (third) parties needed to
consult as part of my application.
 I understand that additional processing fees may be charged.
Your signature
Date
/     /
For help and to
Administration Centre, 62 Flushcombe Road  |  PO Box 63, Blacktown NSW 2148    DX 8117 Blacktown
return this form
www.blacktown.nsw.gov.au    xxxxxxx@xxxxxxxxx.xxx.xxx.xx    02 5300 6000      02 9831 1961
1  Your details
Your ful  name
Company name
(if applicable)
Postal address
Phone
Home
Mobile
Work
Email
 I agree to receive correspondence at the above email address
2  Proof of identity
Only needed if you are asking for access to your personal information.
I have attached a certified copy of:
 Current Australian driver’s licence (includes photo, address and signature)
 Current Australian passport (includes photo and signature)
 Other (document showing proof of signature and address)
3  Information description
Information sought
Please describe the information you seek. Note: If you do not give enough details about the information, we
may not be able to process your application.
Have you applied, at any time, to another
 Yes
If yes, which agency?
agency for similar information?
 No
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Information access
Tell us how you would like to access the information if your request is approved.
 by email
 by post
 I will collect
 I wil  attend your offices to inspect
Disclosure log
If the information sought is released to you and would be of interest to other members of the public, we may
record the details of your application in our ‘disclosure log’ available on our website.
Do you object to details of your application
being included in our disclosure log?
 Yes   No
4  Fees and charges
Application fee
An application fee of $30 is payable with your application.  We must receive payment (options below) before
we can process your application.
Processing fees
You may be asked to pay a charge for processing the application ($30/hr).
You may be eligible to apply for a 50% reduction in processing fees if you are experiencing financial
hardship or if you can demonstrate your application has special benefit to the public.
 I am applying for a discount due to financial hardship.
I have attached evidence (copy of Pension or Centrelink Card)
 I am applying for a discount as access to the information wil  benefit the public because:
Payment details
We will request payment by invoice upon receipt of your application.
You can pay:
 In person
We accept cash, eftpos, cheque or credit card at our Customer Service Centre, located in
our Administration Centre at 62 Flushcombe Road, Blacktown
 Post
You can post a cheque, made payable to: Blacktown City Council, to us at PO Box 63
Blacktown NSW 2148
Your invoice will contain our Bil er Code and your reference number
 Online
Your invoice will contain a reference for payment and a link/web address to access our
online payment portal.  You can pay by debit or credit card.  A surcharge may apply to
payments made by credit card - refer to our Goods and services pricing schedule
available at www.blacktown.nsw.gov.au or on request.
Please email
my invoice to
Formal request to access information
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5  Your right to access information
Under the Government Information (Public Access) Act 2009 (GIPA Act) we are obliged to provide public access to
certain information we hold. Our information can be accessed in 3 ways:
•
Open access -  information on our website, including development applications
•
Informal requests
•
Formal requests
Most requests for information can be satisfied via an Informal request. However, Formal requests must be made for
information that is restricted due to commercial confidence, legal privilege, security or protection of privacy.
If copyright protection restrictions apply, we may allow you to view the information but we wil  not provide you with a
copy.
If the information you are requesting contains information about another person, business or agency, we may be
required to consult with third parties before deciding your application.
If you are unsure whether the information you seek wil  need a formal request, either:
•
contact our Governance Services section on 9839 6000
•
submit an Informal request.  We wil  review your request and advise you if a formal application is needed.
We wil  acknowledge your formal application within 5 workings days and notify you of a decision within 20 working days,
unless you agree to extend this time.  We may also extend the decision time by up to 15 working days where
consultation with a third party is required or we need to retrieve an archived record.
If we do not make a decision or provide you with a response within the above timeframe we are deemed to have refused
the application and wil  refund any fees paid. This wil  not apply if an extension of time has been arranged or payment of
advanced deposit for processing fee is pending.
We are able to defer access, and if this is considered appropriate, we wil  advise the reason and the date the information
wil  be available.
If we refuse access under a formal application, we wil  provide details of the reason(s) for refusal in writing and 3 options
for review:
1. An internal review by a senior employee, who is independent of the original determination.  Applicants have 20
working days from received notice of a decision to ask for this review and it attracts a $40 fee.
2. An external review by the Information Commissioner. If applicants are not satisfied with the internal review, or do not
want one, they can apply to the Information Commissioner. Applicants have 40 working days from receiving notice
of a decision to ask for this review.
3. A review by the NSW Civil and Administrative Tribunal (NCAT). Applicants have 20 days from the date of
notification from the Information Commissioner or 40 days from the date of the original decision to ask for this
review.
Privacy notice
We are col ecting this information to process your request. We may not be able to do so without it. Supplying this
information is voluntary however a completed application wil  meet the formal requirements for making a GIPA
application.
We wil  store your personal information on our systems or in our offices, where it wil  be used by our staff and
contractors. Other people can request access to it under the Government Information (Public Access) Act 2009. You can
ask us to suppress your personal information from a public register and we wil  consider your request in line with the
Privacy and Personal Information Protection Act 1998. Our Privacy Management Plan sets out how you can access or
correct your personal information. Please visit www.blacktown.nsw.gov.au for a copy of the plan.
Office use
Date received
  /     /
Receipt No.
Proof of identity?
Yes No
Formal request to access information
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Document Outline