GIPA Reference Number
Government Information (Public Access) Act 2009 Access
Application Form – Formal Application
Please complete this form to apply for formal access to information held by NSW Police under the
Government
Information (Public Access) Act 2009 (GIPA Act).
Your Details
Name (Family Name,
Title:
Given Name):
Previous Names:
Company Name:
Postal address:
State: Postcode:
Preferred Contact Number:
Email:
I agree to receive correspondence at the above email address.
YES/NO
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 license (with photograph, signature and current address)
Current Australian passport
Other proof of signature and current address details
* Certified means that your proof of identify must be verified (ie - signed and dated) by an authorised person (Justice
of the Peace, doctor, teacher, pharmacist, legal practitioner, Postmaster - Australia Post).
Application fee and processing charges
I attach payment of the $30.00 application fee by
Cheque (Enclose a cheque made payable to NSW Police )
Money order (Enclose a money order made payable to NSW Police)
Credit Card (Authority is to be attached)
I understand that I may be asked to pay additional processing charges.
Please do NOT send cash through the post.
Fee Reduction
You may be entitled to a reduction of fees to $15.00 if :
You have financial hardship - Please attach supporting documentation eg Health Card, Pension or
Centrelink Card
Special benefit to the public - Please specify why?_______________________________________
Government Information
Are you seeking personal information? Yes/No
Are you seeking your Criminal History only? Yes/No
Please describe in detail the information you would like to access to allow the record(s) to be identified.
Event Number:_______________________________ Date of incident: ________________________
Local Area Command incident was reported to: _____________________________________________
However, your application is not valid until you provide enough details to enable NSW Police to identify the
information you are seeking. You can only apply for access to information that is contained in records that
are currently held by NSW Police. NSW Police cannot be required to create a new document in order to
respond to your application but may, if it is more administratively convenient, decide to do so (e.g., create a
summary document rather than to copy all of the source documents.You should supply any additional
information that you feel will support your claim for access to the documents/information.
Note : If the incident you require involves a deceased person which was investigated by the State
Coroner, please enquire with that department prior to applying to this unit.
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Form of access
How do you wish to access the information?
Inspect the document
A copy of the document(s)
Access in another way (please specify) Example: In the form of a CD or DVD.
Consultation
NSW Police may be required to consult with third parties before deciding your application.
Please circle “yes” or “no” below whether you consent to the release of the following
information to any third parties. This information will assist any third party to understand
why you are seeking the information.
If available are you seeking access to Witness Statements?
YES NO
Have you obtained an authority from the other person/s to release their statement to you? YES NO
If ‘YES’, please attach written Authority.
If ‘NO’ consultation with other involved persons may be required.
Please complete the ‘CONSULTATION’ section below.
(To be completed ONLY if the documents you require involve or may involve other persons)
Do you wish for other involved persons to be contacted to obtain their consent to release
information to you? YES NO
Do you understand that to engage in a consultation process, that the time to respond to your
application will be extended by a further 15 days?
YES NO
Do you understand that as the information requested is considered non-personal that additional
charges may apply ?
YES NO
Do you require the personal information of other persons involved (eg name and address)? YES NO
Do you consent to the other party being given your details as the applicant requesting their
information? YES NO
Would you accept a statement without the personal information of the other party? YES NO
Disclosure Log
If the information you have requested is released to you and would be of interest to other members of the public,
details about your application may be recorded in NSW Police’s ‘disclosure log’. This is published on NSW Police’s
website.
Do you object to this? (please tick one)
YES
NO
Note: You will be contacted and given a further chance to object before the document(s)/information is placed on
the Disclosure Log.
Privacy Statement
NSW Police is subject to the
Privacy and Personal Information Protection Act 1998 and the
Health Records and
Information Privacy Act 2002 which requires us to comply with Information and Health Privacy Principles.
Your personal information is being collected to process your application for information pursuant to Part 4, Division 1
of the
Government Information (Public Access) Act 2009. NSW Police may use your personal information for the
purposes of processing your application within the agency.
NSW Police is required to collect personal information directly from the individual unless the individual has authorised
collection of the information from someone else. NSW Police will not disclose your personal information without your
consent unless authorised by law.
Your personal information will be held by NSW Police at 1 Charles Street, Parramatta NSW 2150. You have the right
to access and correct the information if you believe that it is incorrect.
Applicant’s signature: Date:
Applications can be lodged using the following methods:-
Mail
NSW Police
Information Access and Subpoena Unit
Locked Bag 5102
Parramatta NSW 2124
T: 8835 6888
E-Mail
E:
xxxxxxx@xxxxxx.xxx.xxx.xx – A credit card authority
must accompany any emailed application
