Government Information (Public Access) Act 2009
Formal Access Application
Please complete this form to apply for formal access to information under the
Government Information (Public Access) Act 2009 (
GIPA Act).
Your Details
Name: ........................................................................................................................................................
Postal Address: ..........................................................................................................................................
Suburb: ............................................................................................................ Postcode: ......................
Day-time Contact:........................................................................................................................................
Details of Information Sought
Please describe the information you would like to access in enough detail to allow us to identify it.
Note: If you do not supply enough detail, this application may be refused.
...................................................................................................................................................................
...................................................................................................................................................................
...................................................................................................................................................................
...................................................................................................................................................................
...................................................................................................................................................................
...................................................................................................................................................................
...................................................................................................................................................................
...................................................................................................................................................................
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)
...................................................................................................................................................................
Public Interest Test
Under the GIPA Act, a public interest test may apply in considering the release of information sought in
this application. Please state what public interest considerations (if any) should be considered in
determining the application.
...................................................................................................................................................................
...................................................................................................................................................................
...................................................................................................................................................................
Application Fee
I attach payment of the $30 application fee
Processing Charges
Processing charges are $30 per hour. We will contact you to advise estimated costs - you may be
required to make an advance deposit (50%) of the total estimated processing charges.
Applicants seeking personal information (about themselves) are entitled to 20 hours processing time
before additional fees will apply.
Some applicants may be entitled to a 50% reduction in processing charges. If you wish to apply for a
discount, please indicate the reason;
Personal information sought
Financial hardship – please attach supporting documentation - Pension or Centrelink card
Information sought is of special benefit to the public – please specify why below:
...................................................................................................................................................................
...................................................................................................................................................................
Disclosure Log
Under GIPAA Council is required to keep a disclosure log of formal applications.
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 the disclosure log published on the Council's website.
Do you object to this?
Yes
No
Release of Information
Should a third party request it, do you consent to the release of your name as the applicant to this
request?
Yes
No
Lodging the Application
This application may be lodged;
In person - Council's Administrative Centre 1 Stratheden Street Kyogle
By mail - PO Box 11 Kyogle NSW 2474
Applicant’s signature: ........................................................................................ Date: ...............................
General information about the GIPA Act is available by calling the Office of the Information Commissioner on
1800 463 626 or at its website: www.oic.nsw.gov.au