Formal Access Application
(Formerly an FOI application)
Government Information (Public Access) Act 2009 (GIPA)
Please print in BLOCK LETTERS with a black or blue pen
Please complete this form to apply for formal access to government information under the
Government Information
(Public Access) Act 2009 (GIPA Act).
If you need help in filling out this form, please contact the Right to Information Officer on (02) 9716 2662 or visit our
website at www.facs.nsw.gov.au.
Please mark relevant boxes with a If you need more room to answer any questions, please include details on a
separate page and attach it to this form.
Please indicate the type of information you are seeking:
Housing
Child Protection
Ageing and disability
Application number
T File number
Client reference number
If applicable:
Your details
Title
Mr, Mrs, Ms, Miss
Last name or family name
Given name (s)
Unit/House number
Street/Avenue
Town/Suburb
Postcode
Phone
Mobile
Date of birth
DD / MM / YYYY Email
The questions below are optional and the information will only be used for the purposes of providing
better service.
What is the main language you speak at home?
English
No
give details
In what country were you born?
Are you of Aboriginal or
Yes
No
Torres Strait Islander Origin?
give details
Aboriginal
Torres Strait Islander
Aboriginal and
Torres Strait Islander
Proof of identity
Australian Driver’s Licence - with photograph, signature and
current address
When seeking access to government
information, an applicant must provide proof of
Current Passport
identity in the form of a copy of any one of the
Other - proof of signature and current address details
following documents:
(e.g. Health Care Card, Pensioner Concession Card)
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Application fee
Attach payment of the
$30 application fee made payable to the Department of Family and Community Services by
cheque or money order only.
Processing charges
For access to information of a personal nature, the application fee includes 20 hours of processing time, after which a
processing charge of
$30 per hour will apply. For access to information of a non-personal nature, the application fee
covers one hour of processing time, after which a processing charge of
$30 per hour will apply.
Discount in application and processing
Are a holder of a Pensioner Concession Card or Health
charges
Care Card
Some applicants may be entitled to a 50%
A full-time student
reduction in their application and processing
Are a non-profit organisation (including a person applying for or
charges.
on behalf of a non-profit organisation)
If you wish to apply for a discount,
Financial hardship – please attach supporting
please indicate the reason(s).
documentation (e.g. Health Care Card,
Pensioner Concession Card).
Special benefit to the public
give details
Authorising a person/agency to act on
your behalf
Complete this section
ONLY if you are
authorising someone to act on your behalf
Name of person /
agency acting on your behalf
Address of
Unit/House number
Street/Avenue
person / agency
acting on your
Town/Suburb Postcode
behalf
Phone
Mobile
Email
I authorise the persons/agencies named above
to act on my behalf in matters concerning my
Formal Access Application.
I know that I can change my mind and stop my
consent at any time by writing or telling the
Department of Family and Community Services
(FACS) unless there is a current legal order in
place.
Full name (please print)
Signature
U
Date
DD / MM / YYYY
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Information requested
Is it:
Personal information
Non-personal information
Give details of the information you are seeking:
A copy of
Form of Access
How do you wish
Other
the document(s)
to access the
give details
information?
Consent
The GIPA Act requires an agency to consult with
third parties when considering the potential
Yes - I consent to
No - I do not consent to my identity
release of information about the other person’s
my identity as an
as an applicant under the GIPA
personal or other affairs. If we are required to
applicant under the
Act being disclosed.
consult other people about your application, we
GIPA Act being
may need your consent to tell that person that
disclosed.
you are the applicant. Please indicate if you
consent to your identity as an applicant being
disclosed:
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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 the agency’s ‘disclosure log’.
This is published on the agency’s website.
Please note that this does not apply to your
own personal information
Yes
No
Do you object to this?
give details
Signature
Full name
Applicant’s Signature
U
Date
DD / MM / YYYY
Where do I lodge this form?
You can lodge this form by mailing it to:
Right to Information Unit
Department of Family and Community Services
Locked Bag 4028
Ashfield NSW 2131
General information about the GIPA Act is available by calling the Information and Privacy Commission NSW on freecall
1800 472 679 or at its website: www.ipc.nsw.gov.au.
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