Planning Act Form 5 · 132002.220269.1

                   	
                                                                              	
  
                   	
  


       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 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.
                   	
  

                   	
  

                   	
  

                   	
  

	
  

                   	
  




                                                                                                                                  Page 4
                                                                                            Planning Act Form 5 - Change application form
                                                                                                                 Version 1.0—3 July 2017