Application for Waiver or Reduction of Fees
A
PPLICANTD
ETAILSTitle First Name: Surname:
Postal Address: Postcode:
Telephone: (Home) (Business) (Mobile)
Email Address: Fax:
Preferred method of contact: Email Fax Mail Phone:
INITIALAPPLICATION
Application Reference (if known):
GROUNDS FOR WAIVER OR REDUCTION OF FEES
Under Section 156(6) of the Information Act 2002, the Department may waive or reduce a fee payable by an applicant to access government information, having regard to the circumstances of the application and the objects of the Act, including financial hardship.
Note: An application fee does not apply to a request for your own personal information.
Please tick the appropriate box(es)
I am applying for a waiver or reduction of the $30 application fee I am applying for a waiver or reduction of processing fees
INFORMATION IN SUPPORT OF YOURAPPLICATION
Please provide as much detail as you can to support your application, including copies of written documents
Financial hardship:
Other factors:
APPLICANT
’
S SIGNATURE AND DATESign Here: Date: / /
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Application for Waiver or Reduction of Fees
LODGEMENT OF APPLICATION FORM Post the completed form to:
Information and Privacy Unit Legal Services Branch Department of Health PO Box 40596
CASUARINA NT 0811 Or
Email completed form to: [email protected]
For all lodgement queries Phone: (08) 8999 2880
P
RIVACYS
TATEMENTThe Information Act 2002 requires you to provide your name and address for correspondence as well as sufficient details to identify the information you want. Additional contact details assist the Department to process your application. Some personal information may have to be disclosed to other people to satisfy consultation requirements in the Act and make an informed decision on your request. More information about our Privacy Policy is available at www.infoprivacyhealth.nt.gov.au or by contacting the Information and Privacy Unit, DoH.
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