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 need help in filling out this form, please contact  the GIPA
Officer on (02) 8849 6229 or visit our website at www.sydneywater.com.au
Your details
Name:

Postal address:
  Postcode:
Day-time telephone:
Email :
Tick here if you agree to receive communication via email:
Proof of identity
Are you seeking personal information?            Yes    No
When seeking access to your personal information, you  must  provide proof of identity in the form of a certified copy of any
one of the following documents:
Australian driver’s licence
Current Australian passport
Other proof with photograph, signature and current address
Information required
Please describe the information you would like to access in enough detail to allow us to identify it.
Note: If you do not give sufficient details, Sydney Water may refuse to process your application.
Information request period:
From (Date)
To (Date)
1

Government Information (Public Access) Act 2009
ACCESS APPLICATION FORM
Form of access
How do you wish to access the information?
Inspect the document(s)
A copy of the document(s)
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 Sydney Water’s  ‘Disclosure Log’ on Sydney Water’s website.
Do you object to this?
Yes
No
Fees and charges
A fee of $30 applies to applications for formal access under the GIPA Act and must accompany the application. Based
on the complexity of the request and time required for research and retrieval, we may impose additional processing
fees ($30/hour). Our GIPA officer will contact you if the application is likely to result in additional processing fees.
Discount in processing charges
You may be required to pay a charge for processing the application ($30/hour). Some applicants may be entitled to a
50% reduction in processing charge. If you wish to apply for  a  discount,  please indicate the reason:
Financial hardship – provide supporting documentation (eg a copy of pension or Centrelink card).
AND / OR
Special benefit to the public – specify why:
Note: There is no discount applicable to the $30 application fee
Payment options
• Pay by EFT
BSB No:      062 789
Account No:   1915 0587
Quote GIPA as reference and send remittance advice by email xxxx@xxxxxxxxxxx.xxx.xx
• Pay by Mail
Please send a CHEQUE or MONEY ORDER (payable to Sydney Water) along with the application form to  the
address on next page.
2

How to lodge your application
Lodge by email:  xxxx@xxxxxxxxxxx.xxx.xx
Lodge by mail:  Government Information (Public Access) Officer
Level 14
Sydney Water
PO Box 399
PARRAMATTA NSW 2124
Privacy statement
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 requested information assists GIPA officer to respond to the applicant.
If you do not provide the requested information, we may not be able to process the application. Your personal information
will be securely retained in Sydney Water's record keeping system. Sydney Water will not disclose your personal information
without your consent unless authorised or required by the law.
Insert your digital signature below. Alternatively, print this form - sign, scan and send it via post or email.
Applicant’s signature:
Date:
General information about the GIPA Act is available by calling the Information and Privacy Commission on freecall
1800 472 679 or at its website: http://www.ipc.nsw.gov.au
3

Document Outline