(This is an approved form under Section 92 of the Environmental Offsets Act 2014 )
This form must be completed by all land owners who are applying to declare land as an environmental offset protection area in accordance with Section 30 of the Environmental Offset Act 2014 and should be submitted to the
Department of Environment and Heritage Protection .
PART A – PRIMARY CONTACT PERSON DETAILS
Primary contact (All correspondence will be directed to this person.)
Contact name
Postal address of contact
Suburb
State
Country
Primary contact number
Secondary contact number (non-mandatory requirement)
Fax number (non-mandatory requirement)
Email (non-mandatory requirement)
Postcode

Request for Environmental Offset Protection Area declaration
All owners of each parcel of land proposed to be included as all or part of an environmental offset protection area must sign and date this section. Extra pages with names and signatures may be attached if there are additional owners.
Explanatory Note: In accordance with the Environmental Offset Act 2014 an owner , of land, includes the following —
(a) for freehold land —the person recorded in the freehold land register as the person entitled to the fee simple interest in the land;
(b) for land held under a lease
—the person who holds the lease;
(c) for trust land under the Land Act 1994 —the trustees of the land;
(d) for Aboriginal land under the Aboriginal Land Act 1991 —the persons to whom the land has been transferred or granted;
(e) for Torres Strait Islander land under the Torres Strait Islander Land Act 1991 —the persons to whom the land has been transferred or granted;
(f) for a State-controlled road under the Transport Infrastructure Act 1994 —the chief executive of the department in which that Act is administered;
(g) for a road controlled by a local government under the Local Government Act 2009
—the local government;
(h) for other land prescribed under a regulation —the entity prescribed under a regulation for the land.
Statement
I/We
 request the declaration of an environmental offset protection area under the Environmental Offsets Act 2014 over all or part of the land as outlined in Part B of the application;
 consent to the collection and use of the personal information in this form for the purposes of assessing this request for an environmental offset protection area under the Environmental Offsets Act 2014 ;
 solemnly and sincerely declare that the information provided is true and correct to the best of my/our knowledge and I/we make this solemn declaration conscientiously believing the same to be true; and
 understand that all information supplied on or with this application form may be disclosed publicly in accordance with the Right to Information Act 2009 and the Evidence Act 1977 .
Lot and Plan
Date signed
Owner
Signature of owner
Lot and Plan
Owner
Signature of owner
Lot and Plan
Date signed
Owner
Signature of owner
Lot and Plan
Owner
Signature of owner
Lot and Plan
Owner
Signature of owner
Date signed
Date signed
Date signed
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Request for Environmental Offset Protection Area declaration
PART B – DECLARATION AREA
Extent of properties
I seek declaration over (please choose one):
the full extent of all nominated parcels of land; or
the partial extent of at least one nominated parcel of land, as follows:
Lot Plan Extent sought under declaration request
Full Partial
Full
Full
Partial
Partial
Full
Full
Partial
Partial
Spatial information
If the land * proposed for an environmental offset protection area only covers part of a land parcel, or extends past the boundary of a single land parcel, spatial information will be required. Extra pages may be attached to list additional detail. Two options are provided below – please fill in one of these.
Explanatory Note: In accordance with the Environmental Offset Act 2014 land includes water*
If this section is not applicable, please check this box.
Mapping co-ordinates (UTM)
Eastings Northings Zone reference Datum
Map co-ordinates (Geographic co-ordinates)
Latitude (decimal degrees) Longitude (decimal degrees) Datum
PART C – MANDATORY SUPPORTING DOCUMENTATION
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Request for Environmental Offset Protection Area declaration
The following documents, which are designed to achieve a conservation outcome, are attached to this request for declaration:
environmental offset agreement; and
offset delivery plan.
PART D – INTEREST HOLDERS IN PROPOSED ENVIRONMENTAL OFFSET PROTECTION AREA
Each person with an interest in the land (other than the owners of the land) over which the environmental offset protection area may be declared must provide consent to the declaration. This Part provides for recording this consent.
A person with an interest in the proposed environmental offset protection area means:
a person with a registered interest, under the Land Act 1994 or the Land Title Act 1994, in the land area; or
if the land is subject to a lease, mining interest, geothermal tenure or GHG authority – the lessee, interest holder, tenure holder or authority holder;
if the land in the area is forest entitlement area, State forest or timber reserve under the Forestry Act 1959 or land prescribed under a regulation for the purpose of identifying a person with an interest in land – the chief executive of the department in which the Forestry Act 1959 is administered.
Extra pages may be attached to list additional interest holders and their signatures.
Lot and Plan Registered interest Registered interest holder name
Where no lot on plan information is available, please provide spatial information to identify the area of land * the registered interest is over. Two options are provided below – please fill in one of these.
Explanatory Note: In accordance with the Environmental Offset Act 2014 land includes water*.
If this section is not applicable, please check this box.
Mapping co-ordinates (UTM)
Eastings Northings Zone reference Datum
Map co-ordinates (Geographic co-ordinates)
4

Latitude (decimal degrees)
Request for Environmental Offset Protection Area declaration
Longitude (decimal degrees) Datum
Where a person’s interest in the land is assigned under a lease, licence or other authority granted under a law and those interests are affected by the environmental offset agreement associated with the declaration of the environmental offset protection area, has the administering agency that granted the lease, licence or other authority endorsed the environmental offset agreement?
Yes (please attach details of the administering agency’s endorsement)
No (please specify why)
All parties who have an interest in the land to which the environmental offset protection area relates must sign and date this section.
Statement
I/We
 consent to the declaration of an environmental offset protection area under the Environmental Offsets Act
2014 as outlined in Part B of this application;
 consent to the collection and use of the personal information in this form for the purposes of assessing this request for an environmental offset protection area under the Environmental Offsets Act 2014 ;
 solemnly and sincerely declare that the information provided is true and correct to the best of my knowledge and I make this solemn declaration conscientiously believing the same to be true; and
 understand that all information supplied on or with this application form may be disclosed publicly in accordance with the Right to Information Act 2009 and the Evidence Act 1977 .
Registered interest e.g owner, lessee, mining interest, tenure holder, authority holder.
Signature of interest holder
Date signed
Registered interest
Signature of interest holder
Date signed
Registered interest
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Signature of interest holder
Request for Environmental Offset Protection Area declaration
Date signed
Registered interest
Signature of interest holder
Date signed
Registered interest
Signature of interest holder
Date signed
PART E - INFORMATION PRIVACY STATEMENT
The Department of Environment and Heritage Protection (EHP) is collecting the information in this form and any attachments to process a request for the chief executive to declare an environmental offset protection area in accordance with Section 30 of the Environmental Offsets Act 2014 . The consideration of this request may involve consultation, and if so, details of this request and any attachments may be disclosed to relevant third parties.
Personal information will not otherwise be disclosed outside the department unless required or authorised by law.
Office use only ----------------------------------------------------------------------------------------------------
Date received Receiving officer Reference number
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