Form 5 · 51983.3225.12

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

 Date received:                                   Reference number(s):

 QLeave notification and payment
 Note: For completion 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




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