FORMAL REQUEST FOR INFORMATION APPLICATION
Government Information (Public Access) Act 2009 (the GIPA Act)
Please complete this application for formal access to Council information under section 41 of the GIPA
Act. If you need any more assistance, please contact Council’s Governance team on 1300 36 2170 or
visit Council’s website at
www.liverpool.nsw.gov.au 1.
Your details
last name: title: Mr / Mrs / Ms
(circle one)
first name:
telephone contact number:
email address:
postal address (only required if you do not have email):
Please note: Council will usually email all information and correspondence to you, unless you do not
have an email address.
Please provide details below of the Council information that you require (including any
property address) :
2.
Proof of identity (complete only if you seeking your personal information)
If you are seeking access to your personal information, you must provide proof of identity in the form of a
copy
of any one of the following documents
:
Australian driver’s licence
Current Australian passport
with photograph, signature and current address
261433.2014
3.
How do you wish to receive the requested information? (tick one box)
A copy of the document(s) by email
Inspect the document(s) by appointment at Council’s Administration Centre
A copy of the document(s) by post
(only available if you do not have email)
4.
$30 application fee (must be attached to your application)
You must pay the mandatory $30 application fee. Cheques are payable to
Liverpool City Council.
5.
Disclosure log
If this information is released to you and may be of interest to other members of the public, details of
your application may be recorded in Council’s Disclosure Log published on Council’s website.
Do you object to this disclosure?
Yes / No
(circle one)
6.
Discount in processing charges (only in some cases)
If you obtain access to the information sought, you may be required to pay a charge for processing the
application ($30 per hour for Council staff time). If so, you may be entitled to a 50% reduction in
processing charges. If you wish to apply for a discount of these charges, please provide a reason:
financial hardship – please attach supporting documentation (such as a pension or Centrelink card).
AND / OR
of special benefit to the public – please explain below:
7.
You can download this application and post or deliver it:
post: Access to Information Officer, Locked Bag 7064 Liverpool BC NSW 1871
delivery: Council’s Customer Service Centre at Ground Floor, 33 Moore Street Liverpool
8.
Please read the notes below before sending your application to Council
1. Council will use information provided on this form to process this application. It can also be made available by
law to other government agencies. You can find more information about your privacy rights in Council’s Privacy
Management Plan on Council’s website or by contacting Council’s Privacy Contact Officer (the Governance
Coordinator) on 1300 36 2170.
2. Copyright applies to most plans and reports. However, section 43(2)(a) of the
Copyright Act (Cth) 1968 states
that a fair dealing with a literary or artistic work does not infringe copyright in the work if it is for the purpose of
giving professional advice by a legal practitioner. Therefore, if you are a legal practitioner and you are seeking
a copy of a plan or report subject to copyright, you must state in this application, or an attached letter, that you
are a legal practitioner, seeking a copy of the particular plan or report for the purpose of giving professional
advice to one of your clients.
3. For more information about public access to information and privacy please contact the Information and
Privacy Commission on 1800 472 679 or by email: xxxxxxx@xxx.xxx.xxx.xx
