FORM
Official Use
TRIM 16/4974

Application No: ____________
(GC-FO-302)
Payment:_________________
            FORMAL ACCESS TO INFORMATION REQUEST  Date Received:____________
(Application Form)
Receipt No:_______________

Pursuant to section 41 of the Government Information (Public Access)
Act 2009 (GIPAA)

INFORMATION: This form is to assist you to apply for access to information held by Griffith City
Council, pursuant to the Government Information (Public Access) Act 2009  (GIPAA).  GIPAA has
replaced the Freedom of Information Act 1989 (FOI Act).

You are required to pay $30.00 when you lodge this request, pursuant to section 41 of the GIPAA.
Further, this Access Application may incur a process charge of $30.00 per hour, pursuant to
section 64 of the GIPAA. However, section 64(3) provides that your Application fee will count as
payment towards any processing charge that you may be required to pay.

You may lodge this Access Application at Griffith City Council’s Administration Office, 1
Benerembah Street, Griffith during normal business hours, 8.15 am to 4.30 pm, Monday to Friday.

This Access Application will be determined within 20 working days from the date it is received by
Griffith City Council, unless an extension of time applies, in which case you will be duly notified.

1.
Your details
Surname:  ………………………………………………………………Title: Mr  /  Mrs / Ms
Other names:  …………………………………………………………………………………..
Postal address: ……………………………………………………….Postcode:  ………….
Day-time telephone:  …………………………………….  Facsimile:  ………...…….....…
Email:  …………………………………………………………………………………………………….
The questions below are optional and the information will only be used for the purposes of providing better service.
Place of birth:  …………………………..  Main language spoken:  ……………………..
Aboriginal or Torres Strait Islander: Yes / No (circle one)
Do you have special needs for assistance with this application:
………………………………………………………………………………………………………………

I agree to receive correspondence at the above email address.
2.
Proof of identity
Only required when an applicant is requesting information on their own behalf.
When seeking access to personal information, an applicant must provide proof of identity in
the form of a certified copy of any one of the following documents:
  Australian driver’s licence
  Current Australian passport
with photograph, signature and current address
  Other proof of signature and current address details

Approved:  Governance Coordinator
Group / System:
Governance & Compliance
Document ID:  GC-FO-302
Version:  1
Relevant To:
Date Issued: 22 Jan 2016
Revised:
Status:  Current
Page:   1 of 3

FORM
TRIM 16/4974

(GC-FO-302)
            FORMAL ACCESS TO INFORMATION REQUEST
(Application Form)
3.
Government information (information to which you seek access)
Please describe the information you would like to access in enough detail to allow us to identify it.
Note: If you do not give enough details about the information, the agency may refuse to process your
application.
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Are you seeking personal information?   Yes / No  (circle one)
A public interest test will be applied to the information sought in this Access Application. In this
regard if you wish to make a submission as to what public interest considerations you think should
be considered in determining your request, please attach your submission to this form.
4.
Form of access
How do you wish to access the information?
   Inspect the information
   Copy the information
   Access in another way (please specify)
………………………………………………………………………………………………………………….
………………………………………………………………………………………………………………….
5.
Application Fee
I attach payment of the $30 application fee by cash / cheque / money order (circle one).
(Note: please do NOT send cash by post)
6.
Disclosure log
If the information sought is released to you and would be of interest to other members of the public,
details about your application may be recorded in Griffith City Council’s ‘disclosure log’.  This is
published on Council’s website.
Do you object to this?
Yes / No  (circle one)

Approved:  Governance Coordinator
Group / System:
Governance & Compliance
Document ID:  GC-FO-302
Version:  1
Relevant To:
Date Issued: 22 Jan 2016
Revised:
Status:  Current
Page:   2 of 3

FORM
TRIM 16/4974

(GC-FO-302)
            FORMAL ACCESS TO INFORMATION REQUEST
(Application Form)
7.
Discount in processing charges
You may be asked to pay a charge for processing the application ($30 / hour). Some applicants
may be entitled to a 50% reduction in their processing charges.  If you wish to apply for a discount,
please indicate the reason:

(Please tick the appropriate box)

  Financial hardship – please attach supporting documentation (eg a pension or Centrelink card).
(Section 65)

                            AND / OR

  Special benefit to the public – please specify why below: (Section 66)
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
  Waiver of charge for personal information application (20 hours) (Section 67)

We may contact you in writing in the near future if you are required to provide an advance deposit,
pursuant to section 68 of the GIPAA or provide us information regarding your persona factors
pursuant to section 55 of the GIPAA.

If you have other information that may be relevant to the determination of your Access Application,
please provide that information below:

………………………………………………………………………………………………………………….
………………………………………………………………………………………………………………….
Applicant’s signature:  ..........................................................................

Date:   ..................................................................................................
Please post this form or lodge it at: Griffith City Council, PO Box 485, Griffith NSW 2680 or 1
Benerembah Street, Griffith NSW 2680.

Approved:  Governance Coordinator
Group / System:
Governance & Compliance
Document ID:  GC-FO-302
Version:  1
Relevant To:
Date Issued: 22 Jan 2016
Revised:
Status:  Current
Page:   3 of 3

Document Outline