Formal Access Request Form

Formal Access Request Form

Pursuant to section 41 of the Government Information (Public Access) Act 2009

GIPA - Formal Access Application
This is a Formal Access Application for government records held by Yass Valley Council under the Government Information Public Access Act 2009 (GIPA Act).

Applications under the GIPA Act carry a $30 application fee. Further charges may apply for processing based on the staff time required to process your applicaton.

Applications under the GIPA Act must be decided within 20 working days of receipt unless a valid extension is applied. The list of permissable reasons for an extension are outlined under section 57 of the GIPA Act.

Yass Valley Council does not provide records of an individual's personal information. However, you have a right to access records of your own information held by Council. If you are seeking access to your own personal information, please include proof of identity with your submission. ID must be issued by a recognisable authority, such as a drivers licence or passport.

An authorised officer at Yass Valley Council will assess the GIPA application for records and apply a public interest test. You have a right to have any subsequent notice of decision reviewed.

Privacy and personal information protection notice
- This information is voluntarily required to process your request
- Your application will be retained in Council's Records Management System and disposed of in accordance with the Local Government Disposal Authority
- Your personal information can be accessed and corrected at any time by contacting Yass Valley Council

Part A - Applicant Details
Company Name (if applicable)
Name*

TitleFirst NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
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:
AboriginalTorres Strait Islander
Do you have special needs for assistance with this application:
Preferred Method of Communication?*

EmailMail

Part B - Information applied for
Please provide details of the Yass Valley Council records you are seeking to access in the field below, including as many details as possible. *
Note: Applications that are too general, too broad in scope, or may otherwise require a substantial and unreasonable diversion of Council resources may be re-negotiated or refused under the GIPA Act.
How do you wish to access the information?*

Online portalCopies of document(s) - this will incur a charge as per our fees and charges for copying.Other

Part C - Disclosure considerations
Why have you requested the above records from Yass Valley Council?
An explanation for your request is not required under the GIPA Act. However, additional details will assist staff in assessing public-interest considerations for disclosure.
Type of Information - Are you seeking personal information?*

YesNo
Have you applied, at any time, to another agency for similar information?*

YesNo
If yes, please provide the name of the agency
Proof of Identity/Owner Consent

Proof of identity includes Driver Licence, Photo Card or Passport
Cancelof

Part D - Fees and Charges
Applications under the GIPA Act carry a $30 application fee. Additional processing charges may be applied based on the number of staff-hours needed to process your application. Council staff will contact you to request an advance deposit of up to 50% of estimated processing charges.

There are no charges for the first 20 hours of processing of an application for personal information.

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:
If you are applying for a waiver or reduction in processing fees, please select why you are seeking a reduction.

Financial Hardship - please attach supporting documentation (eg a pension or Centrelink card)Waiver of charge for personal information application (20 hours)Special benefit to the public - (under section 66 of the GIPA Act)Other public interest ground to be considered
Pension or Centrelink Card

Cancelof

Part E - 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, the Council may be required to consult with third parties before deciding your application. The purpose of this consultation is for the Council to determine whether the third party has an objection to disclosure of some, or all, of the information being requested. Please indicate whether you consent to your identity as an applicant being disclosed to the involved third party.
Do you object to this?

YesNo

Part F - Disclosure Log
Disclosure Log

If the information sought is released to you and Council considers that it may be of interest to other members of the public, Council may record this in its 'disclosure log' on its website. It may also make the information provided to you available to other members of the public. Please note that your name and other personal information are not disclosed.

You can object to information being included in the Disclosure Log if it includes: Information on applications for personal information regarding the applicant; Information about applications where factors involving the applicant were a consideration in whether or not the disclosure of the information was in the public interest.
Do you object to this?

YesNo

Part G - Public Interest Test
A public interest test will be applied to the information sought through this Formal Access application. Considerations for and against disclosure which may be given weight are listed in the tables under section 12 and section 14 of the GIPA Act.

If you wish to make a submission as to what public interest considerations you think should be taken into account when determining your application, attach your submission to this form.
Applicant Signature*

Clear
Date*

DayMonthYear
Date

Formal GIPA

$30.00AUD Quantity

Total

$0.00AUD

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Please verify that you are human*
Should be Empty:

Formal Access Request Form

Disclosure Log