Access Application
Department of
Government Information (Public Access) Act 2009
Communities and Justice
You may also be able to apply online
at: https://www.facs.nsw.gov.au/about/gipa/right-to-information-policy
Complete this form to apply for access to information held by the Department of Communities and Justice under the
Government Information (Public
Access) Act 2009 (GIPA Act). If you need help completing this form, contact Open Government, Information and Privacy on 02 9716 -2662.
APPLICANT DETAILS
Type of Applicant select from the following
Are you a Care Leaver seeking access to records about your time in out-of-home care?
If you grew up in a children’s home or in foster care, you were in out-of-home care. People who have left out-of-home care are known
as “care leavers”. Care leavers are entitled to access personal information about themselves regarding their time in care by lodging a
request directly with the Care Leaver Records Access Unit,
free of charge. For further information, go to
https://www.facs.nsw.gov.au/families/out-of-home-care/about-out-of-home-care/were-you-in-out-of-home-care, or alternatively,
phon
e 1300 137 160 or 02 9716 2500.
Member of the Public
Legal Representative
Private Sector
Member of Parliament
Media Representative
Not-for-Profit Organisation
Applicant Details or name of client
Title
Family Name
Given Names
Previous Names for members of the public only where applicable
Title
Family Name
Given Names
If applicable, any known client reference number issued by the department, e.g
a tenancy file number, application number, ChildStory reference number, etc.
Date of Birth
Company Name
ABN
Postal Address
State
Postcode
Contact No
Email Address
I agree to receive all correspondence related to this application at the above email address
Yes
No
Proof of Identity
When seeking access to your own personal information, an applicant must provide proof of identity in the form of one of the following
documents.
Please attach a copy of identification to application.
Australian Drivers Licence
Current Australian Passport
Other proof of signature and
x
current address details
AUTHORISING A PERSON / AGENCY TO ACT ON YOUR BEHALF
Attach a separate authority or Complete this section ONLY if you are acting on behalf of another person
Name of person/solicitor/agency
Given Names
Company Name
Postal Address
State
Postcode
Signature:
Department of Communities and Justice – GIPA Access Application Form
Date of Effect: 1 August 2019
Page 1 of 3
Access Application
Department of
Government Information (Public Access) Act 2009
Communities and Justice
You may also be able to apply online
at: https://www.facs.nsw.gov.au/about/gipa/right-to-information-policy
GOVERNMENT INFORMATION
Are there current legal proceedings relevant to your request for information?
Yes
No
Are you seeking access to your own personal information only?
Yes
No
We may remove personal information of other persons and, if appropriate, staff
Yes
No
names from documents. Do you consent to this?
If NO is selected, we are required to consult any third party whose personal information is contained in the records
Date range (if applicable) for the records: From
to
Please indicate the type of information you are seeking:
Housing
Child Protection
Ageing/Disability
Youth Justice
Other
Please provide sufficient detail below* of the information you would like to access, to enable us to identify it. If your application is unclear we may not be able to find it or it may be deemed invalid (e.g statements such as “including
but not limited to…” and “all records held in relation to…” may result in an application being deemed invalid).
*(attach additional pages if necessary)
You can only apply for access to information that is already held by the agency. Attach any additional information or documentation that you feel will
support your claim for access to the requested documents/information.
APPLICATION FEE
I attach payment of the $30.00 application fee by way of:
EFT Transfer
Cheque / Money Order*
Bank Account: Department of Justice Operating Account
If paying by EFT you must attach proof of payment
BSB: 032001
Account number: 201716
to this application
*Cheques/Money orders are to be made payable to the
Department of Family and Community Services
Financial hardship – Some applicants may be entitled to a 50% reduction in the application fee.
If you wish to apply for a discount, please indicate the reason below and attach supporting documents (e.g. Health Card,
Pension or Centrelink card).
Department of Communities and Justice – GIPA Access Application Form
Date of Effect: 1 August 2019
Page 2 of 3
Access Application
Department of
Government Information (Public Access) Act 2009
Communities and Justice
You may also be able to apply online
at: https://www.facs.nsw.gov.au/about/gipa/right-to-information-policy
CONSULTATION
The agency may be required to consult with third parties before deciding the application. Please note that a 10 business day extension
may be applied if consultation is required. For the purposes of consultation, please indicate if the agency can disclose the following
information about you to third parties:
Your name and/or company name
Yes
No
Your reason for making this application
Yes
No
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 (excluding your personal information) may be published in the agency’s ‘disclosure log’ on our website.
Please note that this does not apply to requests for your own personal information.
Do you object to information released being included in the Disclosure Log?
Yes
No
If you do object, please tell us WHY?
PRIVACY STATEMENT
The Department of Communities and Justice (the department) is subject to the
Privacy and Personal Information
Protection Act 1998 and the
Health Records and Information Privacy Act 2002.
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. The provision of personal information is voluntary, however if you
do not provide it we may not be able to process your application. The department may use your personal information for
the purposes of processing your application within the agency. The department will not disclose your personal
information without your consent unless authorised by law. Your personal information will be held by the department.
Generally you have the right to access and correct the information if you believe that it is incorrect. If you wish to do so,
please contact the Privacy Officer by email at
xxxxxxx@xxxx.xxx.xxx.xx or call 02
9377 6000.
Applicant’s Signature*
Date
* by signing this form, I certify the information provided in this form is true and accurate to the best of my
knowledge.
Applications can be lodged using the following methods:
POST
EMAIL
Open Government Information and Privacy
Department of Communities and Justice | Legal
xxxxxxxx@xxxx.xxx.xxx.xx
Proof of a completed EFT funds transfer must accompany
Locked Bag 4028
any emailed application
ASHFIELD NSW 2131
Department of Communities and Justice – GIPA Access Application Form
Date of Effect: 1 August 2019
Page 3 of 3