Form

 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 7 – 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
 Date receipted form sighted by assessment manager
 Name of officer who sighted the form

The Planning Act 2016, the Planning Regulation 2017 and the DA Rules are administered by the Department of
Infrastructure, Local Government and Planning. This form and all other required change application materials should be
sent to the responsible entity.




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                                                                                    Planning Act Form 5 - Change application form
                                                                                                         Version 1.0—3 July 2017