FORMAL REQUEST FOR ACCESS
TO INFORMATION
SECTION 41 GOVERNMENT INFORMATION (PUBLIC ACCESS) ACT 2009
See also Council’s
APPLICANT DETAILS
factsheet “How to
First name
Surname
Access Information held
by Council”
Street number
Street name
Suburb
State
Postcode
Phone number
Email address
Do you have special needs for assistance with this application?
Yes
No
If yes, provide details of
how we could assist.
APPLICATION DETAILS
Please give as much
detail as possible to
help us identify the
information you want to
access.
NOTE: If you do not give
enough details about
the information, Council
may refuse to process
your application,
however Council will
endeavour to assist in
defining the request to a
more manageable one.
Date range of the information required Start date
End date
Are you seeking personal information?
Yes
No
The provision of
personal information is
FORM OF ACCESS
subject to satisfactory
The provision of information is also subject to copyright restrictions; under no
proof of identity being
circumstances will Council reproduce or copy information that is Copyright protected. You
provided if information
will be notified if these restrictions prevent the copying of the information that is sought.
is made available
How do you wish to access the information?
Inspect the information
A copy of the information
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 Council’s website.
Do you object to this?
Yes
No
1
DISCOUNT IN PROCESSING CHARGES
You may be asked to pay a charge for processing the application ($30 / hour). 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).
Waiver of charge for personal information application
Special benefit to the public – please specify:
PAYMENT METHOD
See Council’s adopted
Application fees can be paid by cash, cheque or credit card.
fees and charges at
penrith.city.
• cash, cheque or credit card payments can be paid in person
All fees subject to change
• cheque or credit card payments are accepted by post
• only credit card payments are accepted by email
IMPORTANT
If you are emailing
PAYING BY CREDIT CARD?
payment details, please
Please complete the Credit Card Authorisation Form located in the list of
include the Credit Card
Downloadable Forms and ensure that you provide the full details of the purpose
Authorisation Form as a
of your payment on this form.
separate attachment to
your Application or any
If you are sending your payment by email, please ensure the Credit Card
other information.
Authorisation Form is included in your email as a separate attachment to your
Application or any other information.
Please do not merge
forms together.
DECLARATION
I have read the information provided in relation to copyright and I understand that I am
not entitled to copies of copyrighted information. I understand that I can view information
free of charge, and that if I request copies not protected by copyright provisions, fees are
payable as outlined in Council’s annual schedule of fees and charges.
Signature
Date
PRINT
OFFICE USE ONLY
Receipt No.
Date
CONTACT US
Penrith City Council
PO Box 60
PHONE: (02) 4732 7777
601 High Street
PENRITH NSW 2751
FAX:
(02) 4732 7958
PENRITH NSW 2750
EMAIL: xxxxxxx@xxxxxxxxxxx.xxx.xxx.xx
WEB:
www.penrithcity.nsw.gov.au
