PlanningActForm5-Changeapplicationform (1)

Privacy – Personal information collected in this form will be used by the responsible entity and/or chosen
assessment manager, any relevant affected entity or referral agency and/or building certifier (including any
professional advisers which may be engaged by those entities) while processing, assessing and deciding the change
application.
All information relating to this change application may be available for inspection and purchase, and/or published on
the assessment manager’s and/or referral agency’s website.
Personal information will not be disclosed for a purpose unrelated to the Planning Act 2016, Planning Regulation
2017 and the DA Rules except where:
•     such disclosure is in accordance with the provisions about public access to documents contained in the
      Planning Act 2016 and the Planning Regulation 2017, and the access rules made under the Planning Act 2016
      and Planning Regulation 2017; or
•     required by other legislation (including the Right to Information Act 2009); or
•     otherwise required by law.
This information may be stored in relevant databases. The information collected will be retained as required by the
Public Records Act 2002.


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