GIPA Act - Application To access information held by the Department of Customer Service (including Revenue NSW), submit a request using the form below. Avoid processing delaysWe encourage you to pay the $30 application fee by EFT to avoid delays in processing your application. If you are unable to pay in this way then please contact us on (02) 9219 3700 to discuss. Your details Title - Select -MsMissMrsMrDoctorProfessor First name Last name Name of party on whose behalf you are acting Address Suburb Postcode State - Select -New South WalesAustralian Capital TerritoryVictoriaSouth AustraliaWest AustraliaQueenslandNorthern TerritoryTasmania Primary contact number Secondary contact number Company Email address Proof of identity If you are seeking access to any personal information (including your own), you will need to provide proof of identity or authorisation from the person to which the personal information belongs. Options include: Current Australian Driver's licence Current Australian passport Government-issued identity card Letter of Authorisation (if acting on behalf of somebody) Please attach documentation to your application. Upload your proof of identity One file only.16 MB limit.Allowed types: doc, docx, gif, jpg, jpeg, png, txt, rtf, pdf, ppt, pptx, xls, xlsx. Application fee The fee for a GIPA application is $30. This fee must be paid to successfully lodge an application. Payment options Post cheque or money order with the application form payable to Department of Customer Service. EFT please follow payment instructions below. Subject description: Your surname - GIPA application fee Pay: Department of Customer Service ABN: 81 913 830 179 Bank: Westpac BSB: 032 001 Account number: 203164 Payment type Cheque Money Order EFT payment Government information What information do you want to access? Please describe in detail the information you would like to access. If you do not provide enough detail we may not be able to process your application. Please provide other information that may assist us in finding the relevant information. Discount of processing charges You may be asked to pay a fee of $30 an hour for processing your application. Some applicants may be entitled to a 50% reduction of processing charges on the grounds of personal hardship or because the information sought is of special interest to the public. If you wish to apply for a discount on the processing charges, please indicate the reason: For financial hardship, please attach supporting documentation - copy of pension, Department of Human Services or student card For not-for-profit organisation, please attach supporting documentation For special benefit to the public, please attach supporting documentation Discount reason Financial hardship Not-for-profit organisation Special benefit to the public No Discount Applicable Attach supporting documentation here One file only.16 MB limit.Allowed types: pdf, doc, docx. Disclosure log If the information you have requested is released to you and would be of interest to other members of the public, details about your application may be recorded in the agency’s ‘disclosure log’. This is published on the agency’s website. We will not publish personal information on the log. Do you object to this? Yes No Accessing the information How do you wish to access the information? Inspect the document(s) A copy of the document(s) Data on a spreadsheet Other If Other, please specify Consultation We may need to consult with third parties before deciding your application. Please indicate in the boxes below whether you consent to the release of the following information to any third parties. This information will assist any third parties to understand why you are seeking the information. Your name? Yes No Details of information you are seeking? Yes No Privacy Statement The Department of Customer Service (DCS) is subject to the Privacy and Personal Information Protection Act 1998 and the Health Records and Information Privacy Act 2002, which requires us to comply with Information and Health Privacy Principles. Your personal information is being collected to process your application for information pursuant to Part 4, Division 1 of the Government Information (Public Access) Act 2009. DCS may use your personal information for the purposes of processing your application within the agency. DCS is required to collect personal information directly from the individual unless the individual has authorised collection of the information from someone else. DCS will not disclose your personal information without your consent unless authorised by law. Your personal information will be held by DCS. You have the right to access and correct the information if you believe that it is incorrect. I agree Contact If you require assistance lodging this application you may call the GIPA team on 02 9219 3700 or send an email to email@example.com.