Form W 03Ta – Fill Out and Use This PDF

Section 72 Water Management Act 2000

Before completing this form, carefully read the relevant Registrar General’s Directions available from Land and Property Information (LPI). Failure to do so may lead to rejection. All handwriting must be in block capitals.

PRIVACY NOTE: The Water Management Act 2000 authorises the collection of the information required by this form for the establishment and maintenance of the Water Access Licence Register. That Act allows for public access to the Register and for ministerial disclosure of information contained in the Register.

CODE	DETAILS OF THE PERSON OR FIRM LODGING THIS FORM FOR REGISTRATION AT LPI
AE	(A) Delivery Box	(B) Name, Address or DX, Telephone, and Customer Account Number if any		(C) Reference		(D) Dealing
						No
						of
(E) WATER ACCESS LICENCE NUMBER			(F) LICENCE TENURE TYPE		(G) REGISTERED DEALING

(H)DECEASED REGISTERED HOLDER

(I)APPLICANT

(J)I / We, the above applicant(s), being entitled as the executor of the will / administrator of the estate of the deceased registered holder

(who died on	. . . . . . . . ) pursuant to probate / letters of administration No
granted on	(which is lodged herewith / a certified copy of which is lodged herewith) apply to be registered
as holder of the estate or interest of the deceased registered holder in the		water access licence / registered dealing specified above.
Dated	. . . . . . . . . . . . . . . . . . . . .
(K) I certify that the applicant, with whom I am personally acquainted or as to		Certified correct for the purposes of the Water
whose identity I am otherwise satisfied, signed this dealing in my presence.		Management Act 2000 by the applicant.
Signature of witness:	. . . . . . . . . . . . . . . . . . . . . . . . .	Signature of applicant:
Name of witness:	. . . . . . . . . . . . . . . . . . . . . . . . .
Address of witness:	. . . . . . . . . . . . . . . . . . . . . . . . .	. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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		Evidence sighted & returned [Office use only]:
Form W-03TA(E) ‚ Edition 1204 -¦-		NSW OFFICE OF WATER
	Page 1 of	. . . .LAND AND PROPERTY INFORMATION

1.Separate details must be provided for each licence in the application.

2.This form must be signed by or on behalf of the applicant(s) as on the transmission application itself. The signature(s) need not be witnessed.

3.A contact licence holder must be nominated for each licence. A contact licence holder is the licence holder to whom notices and other correspondence will be sent and who will receive invoices relating to the fees and water charges associated with the licence. Where there are multiple licence holders, one only must be nominated. Where the contact licence holder is a corporation its ABN, ACN or ARBN must be provided. The contact licence holder’s daytime telephone number must be provided. It will be used by the licence regulator or water delivery authority to seek any necessary clarification of information relating to the licence.

4.If the space provided is insufficient attach additional sheets in the same format as this sheet.

Water Access Licence No.	Contact licence holder’s details
	ABN/ACN/ARBN:
	Name:
	Address:
	City/Suburb/Town:	Postcode:
	Daytime telephone number:
	ABN/ACN/ARBN:
	Name:
	Address:
	City/Suburb/Town:	Postcode:
	Daytime telephone number:
	ABN/ACN/ARBN:
	Name:
	Address:
	City/Suburb/Town:	Postcode:
	Daytime telephone number:
	ABN/ACN/ARBN:
	Name:
	Address:
	City/Suburb/Town:	Postcode:
	Daytime telephone number:
	ABN/ACN/ARBN:
	Name:
	Address:
	City/Suburb/Town:	Postcode:
	Daytime telephone number:
The applicant states that the information provided herein is accurate and true.
Signature of applicant:

If signed on the applicant’s behalf by a solicitor or barrister, insert the signatory’s full name and capacity below:

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Form W-03TA(E)-ADD ‚ Edition 1204 -¦-		NSW OFFICE OF WATER
	Page 1 of	LAND AND PROPERTY INFORMATION