FORMAL ACCESS APPLICATION
Please complete this form to apply for formal access to government information under the
Government
Information (Public Access) Act 2009 (
GIPA Act). If you need help in filling out this form, please contact
the Coordinator Governance & Administration on 9335 2016 or visit our website at
www.marrickville.nsw.gov.au.
1.
Your details
Surname:
....................................................................................................
Title: Mr / Ms
Other names:
.............................................................................................................................
Postal address:
.............................................................................................................................
Suburb:
...........................................................................................
Postcode: .............
Day-time telephone: ....................................................
Facsimile: .....................................................
Email:
.............................................................................................................................
2.
Proof of identity
Are you seeking personal information?
Yes / No (circle one)
When seeking access to personal information, an applicant must provide proof of identity.
Council will accept a current Australian driver’s licence, current Australian passport, or other
proof of signature and current address details.
3.
Government information
Please describe the information you would like to access in as much detail as possible to allow us to
identify all the records relating to your application.
Note: If you do not give enough details about the information, Council may not be able to process your
application.
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Scan to TRIM container 3455
MCFA
Please turn over
1
*MCFA*
Government Information (Public Access) Act 2009
FORMAL ACCESS APPLICATION FORM
4.
Form of access
How do you wish to access the information?
Inspect the document(s)
A copy of the document(s)
*
Access in another way (please specify) ............................................................................................
................................................................................................................................................................
* Some documents may not be copied without consent of the copyright owner.
5.
Fees
1. This request attracts a
$30 application fee. You can pay by cash, credit card or eftpos at the
Customer Service Centre Front Counter, or by post with credit card (credit card payment form
available on Council’s website), or a cheque or money order.
2. If you are given access to the information sought, you will be charged an additional processing fee
of $30 per hour.
Some applicants may be entitled to a 50% reduction in their processing charges. If you wish to
apply for a discount, please indicate reason:
Financial hardship (hold current Pensioner Concession card issued by the Commonwealth
or are a full time student with proof of study load)
AND / OR
Special benefit to the public (not for profit organisation or acting on behalf of a not for profit
organisation) – please specify why below and provide evidence:
................................................................................................................................................................
................................................................................................................................................................
Note: Please note that if you are seeking personal information about yourself you will not be charged a processing fee for the
first 20 hours taken to process your application.
6.
Disclosure log
Some details concerning the nature of your Formal Access request will be recorded in Council’s
disclosure log, which is published on Council’s website.
Under the Act there are some grounds for objection to the inclusion of information on the disclosure
log. These are:
•
the information includes personal information about the applicant (or a deceased person for
whom the applicant is the personal representative),
•
the information concerns the applicant’s business, commercial, professional or financial
interests,
•
the information concerns research that has been, is being, or is intended to be, carried out by
or on behalf of the applicant,
•
the information concerns the affairs of a government of the Commonwealth or another State
(and the applicant is that government).
If you object to the nature of your application being included in Council’s disclosure log, on any
of the grounds stated above, please attach supporting documentation / letter / declaration.
Please turn over
2
Government Information (Public Access) Act 2009
FORMAL ACCESS APPLICATION FORM
7.
Applicant’s signature
Applicant’s signature: .........................................................................
Date: .................................................................................................
8.
Your privacy
The personal information you have supplied on this form is required to assist Council officers when
determining your application. Failure to provide some details may result in rejection or delays. The
details provided are not publicly available. At any time you have access to view or correct any
information you have supplied. The information you have supplied will be held at Council offices.
Please post this form or lodge it at:
Marrickville Council Customer Service Centre
2 Fisher Street Petersham NSW 2049
DX 3910 Annandale
PO Box 14 Petersham NSW 2049
www.marrickville.nsw.gov.au
xxxxxxx@xxxxxxxxxxxx.xxx.xxx.xx
Phone 02 9335 2222 Fax 02 9335 2029
Monday – Friday 8:30am – 5:00pm
Office use only
Date application received: ................................................................................
Amount Paid: ...................................................................................................
Receipt Number: ...............................................................................................
TRIM reference: ................................................................................................
Merit reference:.................................................................................................
Proof of Identity:................................................................................................
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