Form 5 - Change Application

 Note: Relevant plans are required to be submitted for all relevant aspects of this change application. For further
 information, see DA Forms Guide: Relevant plans.


 14) Applicant declaration
     By making this change application, I declare that all information in this change application is true and correct.
     Where an email address is provided in Part 1 of this form, I consent to receive future electronic communications
     from the responsible entity and any relevant affected entity or referral agency for the change application where
     written information is required or permitted pursuant to sections 11 and 12 of the Electronic Transactions
     Act 2001.
 Note: It is unlawful to intentionally provide false or misleading information.
 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