DA Form 5

PART 8 - FOR COMPLETION OF THE ASSESSMENT MANAGER - FOR OFFICE
USE ONLY

 Date received:                                   Reference number(s):

 QLeave notification and payment
 Note. For wnipletion by assessment manager if applicable
 Description of the work________________________
 QLeave project number
Amount paid ($)                                                   Date paid (dd/mm/yy)
 Date receipted form sighted by assessment manager
 Name of officer who sighted the form




                                                                                                                                Page 5
                                                                                         Planning Act Form 5 - Change application form
                                                                                                       Version 1.2 — 7 February 2020