0015D13F.001

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         INTEGRATED PLANNING ACT 4997,                                                                                 Part E, Version 2.1, 18 June 2007.
                                                                     PLEASE NOTE
        .                               This application cannot be accepted unless accompanied by Part A of Form 1.
              The assessment manager may refuse to accept an application that, at the time of lodgement, fails to provide all applicable information
                                                  requested by Part A and any other relevant part of Form 1.
           OFFICE USE ONLY (applicable to assessment manager)
               ’                                                   REFERENCE

          {i)   Is aPLSL levy applicable in this instance?                 JNO                   L_] YES - complete Q(ii)
          (i)   Has the approved form (issued by QLeave and which signifies that the PLSL levy has been paid) been sighted by the assessment
                manager / private certifier at the time of lodgement of this application?
                [_] NO                           [_] YES - provide receipt details                                                       ;