Appendix A - Form 5

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