Government Information (Public Access) Act 2009
ACCESS APPLICATION
Please complete this form to apply for formal access
Office use only
to government information under the
Government
Information (Public Access) Act 2009 (
GIPA Act).
If you need help in filling out this form, please contact
Application for information
Council on (02) 6623 3800.
Application for review of decision
(
go to Section 5 for fees)
Completed forms:
Post: PO Box 230, Lismore NSW 2480
Delivery: Level 4, 218-232 Molesworth Street, Lismore
Email
xxxxxxx@xxxx.xxx.xxx.xx
1.
Your details
Surname:
.........................................................................................................................................
Other names:
.........................................................................................................................................
.
Postal address:
.................................................................................................
Postcode: ....................
Day-time telephone: ............................................................
Mobile:
..........................................................
Email:
..........................................................................................................................................
The questions below are optional and the information will only be used for the purposes of providing better service.
Place of birth: ..................................................
Main language spoken: ...................................................
Aboriginal or Torres Strait Islander: Yes
No
(please tick one).
Do you have special needs for assistance with this application: ...............................................................
..............................................................................................................................................................................
I agree to receive correspondence at the above email address.
2.
Proof of identity
Only required when an applicant is requesting information on their own behalf.
When seeking access to personal information, an applicant must provide proof of identity in the form
of a certified copy of any one of the following documents:
Australian driver licence
Current Australian passport
with photograph, signature and current address
Other proof of signature and current address
details
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3.
Government information
Please describe the information you would like to access in enough detail to allow us to identify it.
Note: If you do not give enough details about the information, the agency may refuse to process your
application.
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
Are you seeking personal information? Yes No (please tick one)
If you have applied at any time to another agency for substantially the same information, please provide the
name
of the other agency..................................................................................................................................
4.
Form of access
How do you wish to access the information?
Inspect the document(s)
A copy of the document(s)
Access in another way (please specify) .....................................................................................................
5.
Application fee
I attach payment of the
$30 application fee by...
EFTPOS
Credit card
Cheque
I attach payment of the
$40 review of a decision fee by...
EFTPOS
Credit card
Cheque
6.
Third Party Consultation
Under section 54 of the GIPA Act, if the information you are requesting contains information about another person,
business or government agency, Council may be required to consult with third parties before deciding your
application. The purpose of this consultation is for Council to determine whether the third party has an objection to
disclosure of some or all of the information being requested.
Do you object to this? Yes No (please tick one).
7.
Disclosure log
If the information sought is released to you and would be of interest to other members of the public, details
about your application may be recorded in Council’s ‘Disclosure Log’. This is published on Council’s
website www.rous.nsw.gov.au
Do you object to this? Yes No (please tick one).
8.
Discount in processing charges
You may be asked to pay a charge for processing the application ($30/hour). Some applicants may be entitled
to a 50% reduction in their processing charges. If you wish to apply for a discount, please indicate
the reason:
Financial hardship – please attach supporting documentation (e.g. a Pension or Centrelink card).
AND / OR
Special benefit to the public – please specify why below:
..............................................................................................................................................................................
..............................................................................................................................................................................
Applicant’s signature: ................................................................
Date: ......... / ......... /..........
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