Formal Access Application 
Section 9 of the Government Information 
(Public Access) Act 2009 
This form is required to access information available under the Government  
Introduction 
Information (Public Access) Act 2009.  
Note: An application may take longer than 20 days, depending upon the amount of research required 
 
and whether or not it involves a third party. 
A $30.00 application fee applies when you submit a formal access application 
Fees 
form under the Act.  
Applicant  
Surname: ………………………………………………………………………………….  
details 
 
Title: Mr / Mrs / Miss / Ms (Please circle) 
First Name: …………………………….. 
……………………………………………………………………………………………… 
Postal Address:  
 
…………………………………………………………………………………………….. 
 
Suburb: ……………………………………..  Post Code: ……………………………… 
 
Telephone (daytime) ……………………...  Mobile: ………………………………….. 
 
Email: ……………………………………. 
Fax: ……………………………………. 
When seeking access to personal information, an applicant must provide proof of 
Proof of Identity  identity in the form of a certified copy of any one of the following documents: 
Australian driver’s licence 
Current Australian Passport  Other proof of signature and    
(with photograph, signature and 
current address details 
current address) 
Council Information 
 
Detailed description of information required: 
…………………………………………………………………………………………………………………… 
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Application 
Please tick the relevant box: 
 
 
Type 
Do these documents contain information about your personal affairs? If no, additional processing 
fees will apply  
 
 
YES 
NO 
OFFICE USE -  
INTERNAL REFERENCE NUMBER: 
 
OFFICE USE – CASHIER CODE 
AMOUNT PAID 
DATE 
RECEIPT NUMBER 
SIGN 
200 
 

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Form of Access  Do you wish to inspect the documents? 
YES 
NO 
 
Do you require a copy of the documents?    YES 
NO 
 
Other (please specify) 
 
If the information sought is released to you and would be of interest to other 
Disclosure Log 
members of the public, details about your application maybe recorded in  
Council’s ‘Disclosure Log’. The Disclosure Log is published on Council’s website. 
 
Do you object to this? 
YES 
NO 
Reduced Fees 
A 50% reduction in fees will be granted to holders of Pensioner Health Benefit 
Cards or those with equivalent incomes. Non-profit organisations may also be 
able to demonstrate financial hardship and receive a similar reduction. In addition, 
where a demonstrated public interest is involved a similar reduction may apply. 
Are you claiming a reduced fee? If yes, please attach relevant  YES 
NO 
documentation.  
Privacy  
The personal information you have supplied on this form assists Council Officers 
Notification 
in determining your application. The supply of information is voluntary. If you do 
not provide all details requested, Council may be unable to process your  
application. The details you provide are stored at Council Offices and are not 
made publicly available. For more information about your privacy please contact 
Ashfield Council on 9716 1800. 
Applicant’s  Declaration   
 
1. 
I agree to pay all required fees in accordance with Council’s adopted fees 
and charges 
2. 
I declare that all the information given on this application form is true and 
correct. 
3. 
I understand that I must seek the copyright owner’s consent in order to use 
any part of a copyright document for any other purpose.  
 
 
 
Signature  …………………………………………………… 
Date ……………………………... 
Lodgement  
 
Details 
By Post  
PO Box 1145 
(please do not 
Ashfield NSW 1800 
send cash by 
post)  
In Person 
260 Liverpool Road 
Ashfield NSW 2131 
 
 
 

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