Government Information
(Public Access) Act 2009
Access Application
Important information about this form: Please read carefully before completing your application
1. This form is to be used for access to information held by Council.
2. Council will provide access to information it holds except where there is a legal requirement
exempting Council from releasing the document or where there is an overriding public interest
against disclosure of the information.
3. Applications for access to information will be assessed according to relevant legislation and
Council procedures.
Fees and charges:
1. Informal Requests
-
There is no application fee for informal requests. Fees may apply for Council publications or for
photocopying.
2. Formal Requests
-
There is a $30 application fee for formal applications under the Government Information
(Public Access) Act 2009 NSW (‘GIPA Act’).
-
A processing charge of $30 per hour for formal applications under the GIPA Act will also apply
if the information requested does not relate to the applicant’s personal affairs or if a request
for personal information takes more than 20 hours to process. A 50% reduction in fees may be
granted for applicants claiming financial hardship or special public benefit reasons when
requesting the information. Estimates will be provided prior to commencing the information
search.
PART 1 – APPLICATION DETAILS
I am submitting an informal request for access to Council information (no application fee)
I am submitting a formal request for access to Council information ($30 application fee)
Note:
Council encourages applications to be made as informal applications in the first instance. However, Council may
advise that certain applications, such as those involving third party information may need to be made as formal
applications.
PART 2 – APPLICANT DETAILS
Title
Given/First Names
Surname
Address:
Town/City:
State:
Postcode:
Phone/Mobile:
Email:
I agree to receive correspondence at the above email address.
Government Information Access Application V3
PART 3 - 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 licence with photograph, signature and current address
Current Australian passport
Other proof of signature and current address details
PART 4 – DESCRIPTION OF INFORMATION REQUESTED
Please describe the information you would like to access in enough detail to allow us to identify it.
Note: If you do not give enough details about the information, the agency may refuse to process your application.
This information relates to my personal affairs
Yes
No
I am the owner of the property
Yes
No
Other, please specify
If the information sought relates to a property, please complete the section below:
Street Address
Lot No
DP or SP No
Form of information requested:
Inspection
Copy
Copy by email
Other Please describe
Government Information Access Application V3
PART 5 – OWNERS CONSENT
As the owner of the property located at
I give consent to
Owners signature
to make this application
PART 6 – FORMAL REQUEST APPLICATION FEE (IF REQUIRED)
I attach payment of the
$30 application fee by:
Cash
Cheque
Money order
(Note: please do NOT send cash by post)
PART 7 – 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 information will then be published on our website.
Do you object to this?
Yes
No
PART 8 – SIGNATURE OF APPLICATION
As the applicant to this application, I declare that:
1.
I agree to pay all required fees associated with this application.
2.
I declare that the information given on this form is true and correct.
3.
I understand that I must seek the copyright owner’s consent in order to use any part of a copyright
document.
Signed:
Date:
PART 9 – HOW TO LODGE THIS APPLICATION
Post: Lithgow City Council, PO Box 19, Lithgow NSW 2790
In person: Council Administration Building, 180 Mort St Lithgow NSW 2790
Email: xxxxxxx@xxxxxxx.xxx.xxx.xx
OFFICE USE ONLY
Date application received:
Receipt No:
PRIVACY & PERSONAL INFORMATION PROTECTION NOTICE.
By completion of this form you may be providing Council with personal information. Council will collect the information only for a lawful purpose
directly related to the function of Council. Information provided to Council may be used in conjunction with any of Council’s business operations. We
will take reasonable care not to disclose personal information. Exempt documents may come under the Government Information (Public Access) Act
2009.
Government Information Access Application V3
