Government Information (Public Access) Act 2009
Access Application Form
Please complete this form to lodge a formal application to access information held by Service NSW under the
Government Information (Public Access) Act 2009 (GIPA Act).
Please note that Service NSW does not hold
information on behalf of other agencies, such as Transport for NSW (including Roads and Maritime Services)
and NSW Police. To access information held by these agencies, you will need to apply to them directly.
If you need help filling out this form, please contact us on the GIPA Hotline:
(02) 9219 3700
Or email:
xxxx@xxxxxxxxxxxxxxx.xxx.xxx.xx
1. Your details
Name (family name, given name):
Title:
Name of party on whose behalf you are acting (if applicable):
Company name:
Postal address:
State:
Postcode:
Primary contact number:
Secondary contact number:
Email:
I agree that Service NSW will contact me to discuss this GIPA application by phone and/or email.
I agree that Service NSW may ask for proof of identity if my request is for personal information.
2. Requested information
Please describe in detail the government records you would like to access.
Note: • Your application is only valid if you provide enough details to enable Service NSW to identify the information you are seeking.
• GIPA is for access to information that is contained in records that are currently held by Service NSW.
• Service NSW is not required to create a new document in order to respond to your application but may do so, if it is more
administratively convenient (e.g. create a summary document rather than copy all of the source documents).
• GIPA is not for asking questions, unless the answer to your question is already contained in a record that is currently held by
Service NSW.
July 2023
Government Information (Public Access) Act 2009 Access Application Form 1
3. Form of access
How would you prefer to access the information?
Inspect the document(s)
A copy of the document(s)
Access in another way (please specify)
4. Consultation
Service NSW may be required to consult with third parties before deciding your application.
Please indicate in the boxes below whether you consent to the release of the following to any third parties.
Your name and/or company name: Yes No
Details of information you are seeking: Yes No
Note: This information will assist any third party to understand why you are seeking information.
5. Disclosure log
If the information you have requested is released to you and would be of interest to other members of the public, details about
your application may be recorded in the Service NSW disclosure log. This is published on Service NSW’s website.
Do you object to this?
Yes
No
Note: You will be contacted and given a further chance to object before the information is placed on the disclosure log.
6. Application fee and processing charges
I attach payment of the $30 application fee by (please select one):
Electronic Funds Transfer (EFT) –
recommended:
Subject description: Your surname – GIPA application fee
Pay: Department of Customer Service
ABN: 81 913 830 179
Bank: Westpac
BSB: 032 001
Account number: 203164
Attach proof that EFT payment has been made (e.g. a screenshot). The application will not be valid until proof of payment is
received.
Credit card (credit card payments can be made at Service NSW Centres – please attach proof of payment)
Cash (can be made at selected Service NSW Centres – please attach proof of payment and do not send cash by post). Go
to
service.nsw.gov.au and search ‘locations’ then enter your postcode, select the location and the ‘Plan ahead’ tab has
payment information
Cheque (enclose a cheque made payable to the Department of Customer Service)
Money order (enclose a money order made payable to the Department of Customer Service)
Required:
I understand that additional processing charges of $30 an hour apply to GIPA applications, and I may be asked to pay this.
7. Discount of processing charges
You may be asked to pay a fee of $30 an hour to process your application. Some applicants may be entitled to a 50% reduction
of processing charges (discount does not apply to the application fee) on the grounds of personal hardship or because the
information sought is of special interest to the public. If you wish to apply for a discount on the processing charges, please
indicate the reason below. Please note, we shall contact you if we require supporting documents.
Financial hardship
Not-for-profit organisation
Special benefit to the public
No discount applicable
July 2023
Government Information (Public Access) Act 2009 Access Application Form 2
8. Privacy statement
The Department of Customer Service (DCS) supports Service NSW to manage applications under the
Government Information
(Public Access) Act 2009 (the GIPA Act). DCS and Service NSW are collecting the personal information in this form for this
purpose. The information will be used to process your application in accordance with the GIPA Act and the
Privacy and Personal
Information Protection Act 1998. We may share your application with another agency if they hold or are likely to hold the
information you have requested. Otherwise, we will not disclose your personal information without your consent unless
authorised by law. Please see ou
r Privacy Collection Notice for GIPA applications for further details.
9. Lodgement and contact details
To lodge this form:
Complete the form and email a copy to: xxxx@xxxxxxxxxxxxxxx.xxx.xxx.xx (recommended)
Lodge in person at your nearest Service NSW Centre
Post this form to the Service NSW GIPA team at:
Service NSW GIPA Team
McKell Building
2–24 Rawson Place
SYDNEY NSW 2000
If you have any questions, please call the Service NSW GIPA team on (02) 9219 3700.
Applicant’s signature: Date:
- FOR OFFICE USE ONLY -
Proof of identity verification
Proof of Identity requirement – Instructions for Service Centre staff
Sight customer identification document(s) and complete the questions below. A copy of the document is NOT required.
Please scan and return the completed application to the DCS GIPA team using the SHIFT process.
Date completed:
Completed by (name of the officer):
Service Centre:
List of identity document(s) presented by
the customer:
Do NOT record POI information
Is the POI document current?
Yes
No
Does the customer’s name in Part 1 match the name on the document?
Yes
No
Do the contact details in Part 1 match those on the document?
Yes
No
Is the customer identifiable as the person photographed on the document
(if photo ID provided)?
Yes
No
N/A
Additional notes (if any):
July 2023
Government Information (Public Access) Act 2009 Access Application Form 3
