DA Form 5 · MCU26/0012.01

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    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
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                                                                                                                  1.2 — 7 February 2020