GIPA Formal Access Application  
Version 4 - 17 October 2014 
 
 
Government Information (Public Access) Act 2009 
ACCESS APPLICATION 
Please complete this form to apply for formal access to government information under the Government 
Information (Public Access) Act 2009 (GIPA Act).  If you require assistance filling out this form, please 
contact the Access to Information Officer on (02) 49210481 or visit our website at www.lakemac.com.au 
1. Your details 
Surname:  
............................................................................................ 
 
 
Title:  …………  
First name:  
....................................................................................................................... 
 
Organisation Name (if applicable):     …………………………………………………………………….. 
Postal address:  
..................................................................................... 
……………………… 
Postcode:  
…………………….. 
Day-time telephone: …………………………………………… 
 
Facsimile:  …………………………. 
Email:  
 .......................................................................................................................     
    I agree to receive correspondence at the above email address. 
2. Government information 
Please clearly describe the information you would like to access with enough detail to allow us to 
identify it.   
Note: If you do not give enough details about the information requested, the agency may refuse to process 
your application.   
 ............................................................................................................................................................  
 ............................................................................................................................................................  
 ............................................................................................................................................................  
 ............................................................................................................................................................  
 ............................................................................................................................................................  
 ............................................................................................................................................................  
 ............................................................................................................................................................  
Are you seeking personal information?   
   Yes /   
    No   
Note: Personal information means information or an opinion about an individual whose identity is apparent or 
can reasonably be ascertained from the information. 
Lake Macquarie City Council 
Page 1 of 2 
 

---

GIPA Formal Access Application  
Version 4 - 17 October 2014 
 
3. Form of access 
Our preferred method for releasing information is via email.  If you wish to access the information 
in another way, please indicate below: 
   A photocopy of the document(s)                                    
   Inspect the document(s) 
   Access in another way (please specify)   …………………………………………………………….. 
4. Disclosure log 
If the information sought is released and Council feels it would be of interest to other members of 
the public, details about your application may be recorded in Lake Macquarie City Council’s 
‘Disclosure Log’.  This is published on Council’s website. 
Do you object to this?   
  Yes  /   
    No   
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.  The application fee is the prescribed fee as per the GIPA Act and will not be 
discounted or waived). 
6.  Discount in processing charges 
Your application may be the subject of an additional processing charge of $30 per hour; however, if 
your application relates to your personal information, the first 20 hours of processing time are free.  
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: 
    Financial hardship – please attach supporting documentation (e.g. a pension or Centrelink 
card). 
 AND 
/ 
OR 
    Special benefit to the public – please specify why below: 
 ............................................................................................................................................................  
 ............................................................................................................................................................  
Applicant’s signature: ……………………………………………….............   Date: …………………………….
__________________________________________________________________________________ 
Please post this form or lodge it at: 
Lake Macquarie City Council 
 
 
 
 
 
 
 
126-138 Main Road, Speers Point NSW 2284   
 
 
 
 
 
 
 
 
 
Box 1906 Hunter Region Mail Centre 2310 
General information about the GIPA Act is available by calling the Information and Privacy Commission NSW on 
enquiries line 1800 472 679 or on its website: www.ipc.nsw.gov.au 
Office use only 
Date application received: ................................................................................  
Paid: …………………………………………………………………………………. 
Lake Macquarie City Council 
Page 2 of 2 
 

---