Governance and Risk
(02) 4645 4330
Formal Release Application as per Government Information (Public Access) Act 2009 (NSW)
Privacy Statement
The information requested by Council on this form may constitute personal information under the
Privacy and Personal
Information Protection Act 1998 (NSW). Council is allowed to collect the information from you to consider this matter. Supplying
this information is voluntary. However if you cannot or do not wish to provide the information, we may not be able to conside r the
matter. If you need further details, please contact the Privacy Officer, Campbelltown City Council, Cnr Queen and Broughton
Streets, Campbelltown.
Information
Please complete this form to make a formal access application under s41 of the
Government Information (Public
Access) Act 2009 (the GIPA Act).
A formal application is necessary when the requested information is of a sensitive nature, the records being sought
are not readily accessible (such as archived or historical records) and where the request will take significant time t o
process.
For further assistance, please contact Council’s Governance Officer – Access to Information on (02) 4645 4330 or
email at
xxxxxxxxxxxx@xxxxxxxxxxxx.xxx.xxx.xx or visit our website at
www.campbelltown.nsw.gov. au.
1. Your details
Company Name (if applicable): ________________________________________________________
Surname: ______________________________ Other names: _______________________________
Postal address: _____________________________________________________________________
Contact number: ___________________________ Facsimile: _______________________________
Email: ____________________________________________________________________________
Are you seeking your own personal information? Yes / No (circle one)
If yes, the applicant must provide proof of identity in the form of certified copy. Only required when
applicant is requesting information on their own behalf.
Proof of Identity: ____________________________________________________________________
2. Government information being sought
Please describe the type of information you would like access to in enough detail for us to identify it:
(Alternatively attach a schedule of requested documents / information to your application):
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
__________________________________________________________________________________
DATA AND DOCUMENT CONTROL
Governance and Risk
Revised Date: 04/06/2018
Version: 5
DocSet: 5046020
Review Date: 30/06/2020
Page 1
3. Form of access
How do you wish to access the information? (please tick)
Electronic Copy by Email – Documents will be supplied via email.
Inspect the document(s) – Documents will be made available for inspection at Council.
A copy of the document(s) – Photocopying charges will apply. See fees’ & charges on Councils’ website.
Please note:
1. Documents can be subject to Section 36 of the
Copyright Act 1968 (Cth) w hich protects copyright in relation to plans, technical
reports and documents and as such Council is unable to reproduce these documents w ithout the express w ritten permission of the
copyright ow ner. Where possible Council w il try to supply details of the Copyright Ow ner so that you can obtain the necessar y
permission.
2. Plans and specifications for any residential parts of a proposed building cannot be provided to third parties.
3. Depending on the age of the property, there may be a lack of documentation, and the documents that are available may be of poor
quality.
4. Application fee
I attach payment of the $30 application fee by (please tick):
Cash (Please submit in person and pay at Council, do not send cash in the post)
Cheque (Should be made out to Campbelltown City Council)
Money Order (Should be made out to Campbelltown City Council)
Credit Card (A Credit Card Payment Authorisation Form will be made available upon request)
I request an invoice (the application is not valid until the payment is received by Council)
If you are given access to the information sought, you may be asked to pay a charge for processing the
application ($30 per hour). Some applicants may be entitled to a 50 per cent reduction in their
processing charges. If you wish to apply for a discount, please indicate the reason:
Financial Hardship – please attach supporting documentation (e.g. Pension or Centrelink Card)
AND/OR
Special benefit to the public – please specify why below:
5. 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 Council’s Disclosure Log. This is published on
Council’s website.
Do you object to this?
Yes / No (circle one)
6. Signature
Applicants Signature: ________________________________________ Date: ____________________
Council will process the application within 20 working days after receipt of a valid completed application.
This form can be lodged with Campbelltown City Council either:
In person:
Civic Centre, Cnr Queen & Broughton St, Campbelltown
By Post:
PO Box 57, Campbelltown NSW 2560
By Fax: (02) 4645 4387
Email:
xxxxxxx@xxxxxxxxxxxx.xxx.xxx.xx
This form can be completed online just visit
Councils website and see ou
r Access to Information page,
use the links provided to submit an online application.
Office Use Only:
Date application received: ____________________________________ Payment Received: Yes / No (receipt to GL 1-3335-000-2316)
Received by (Officer): __________________________________________ Reference No.: _____________________________________
DATA AND DOCUMENT CONTROL
Governance and Risk
Revised Date: 04/06/2018
Version: 5
DocSet: 5046020
Review Date: 30/06/2020
Page 2