SPLES10786 V03 June 2013 Form 2IP
Information Privacy Personal Information
Amendment Application
Information Privacy Act 2009 (section 44)
Note:
................................... denotes Mandatory field.
Contact Details
You are required to supply your name and an address for correspondence. Additional contact details will help us to deal with your application, and to
correspond with you in the manner you prefer. If you are applying on behalf of another person, please complete this section with your contact details.
Title (e.g. Mr, Mrs, Ms, Miss) Given name/s Family name
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Postal address
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......................................................................................................................................................................... Postcode: .............................................
Preferred method of contact (Please indicate by number in order of preference, your preferred method of contact. If you choose email or post, please
also provide a contact telephone number so that the agency may contact you to clarify aspects of your application.)
Phone
Fax Mobile Email Post
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Application Details
1. Are you seeking to amend information on someones behalf?
No
Yes
Family name ........................................................................ Given name/s ...........................................................................................
Please attach proof of your authorisation to act on the persons behalf.
(for example: a client agreement if you are a solicitor) or written authorisation from the person concerned.
If you are an eligible family member, and you wish to amend documents on behalf of a deceased relative, you must provide proof of your relationship
to the relative.
Note: Eligible family members include a spouse, adult child of the deceased person (if the spouse is not available), a parent of the deceased person (if neither the spouse
nor the adult child are available) and others as listed in the IP Act. Please contact the RTI officer if you are uncertain as to whether you are an eligible family member.
2. Which agency/s are you applying to?
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Please read the following information carefully before proceeding with your application.
Under the Information Privacy (IP) Act 2009 you have a right to amend your own personal information. Many agencies have administrative practices
that allow you to amend your own personal information without entering into a formal application process under the IP Act. lt is recommended you
contact the relevant agency for advice about administrative options available to you before completing and submitting this form.
If you wish to make a formal application to amend personal information under the IP Act, this is the approved form.
Under the IP Act, you may apply to amend documents containing personal information where you believe relevant information is inaccurate,
misleading, out of date or incomplete. There are no fees or charges for the application, but you will be required to provide evidence of your identity.
Great state. Great opportunity.
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SPLES10786 V03 June 2013 Form 2IP
3. Particular details:
Please specify and detail information about the amendment you seek:
a. Describe the document/s you wish to amend, and select from the options below:
Letter / Memo
Report
File
Form
Other (please specify):
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b. If you claim that personal information is inaccurate or misleading, please provide an explanation of how or why the personal information is inaccurate or
misleading (include the changes proposed so that the personal information is not inaccurate or misleading). If possible, please attach a copy of the relevant
document/s, with appropriate passages marked for the RTI officer’s reference.
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c. If you claim the personal information is out of date or incomplete, please provide an explanation of what information is necessary to render the document up
to date or complete (include the changes proposed so that the personal information is not out of date or incomplete). If possible, please attach a copy of the
relevant document/s, with appropriate passages marked for the RTI officer’s reference.
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d. Provide any other supporting information that you believe will assist assessing of your application. (Attach additional pages if necessary)
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4. Evidence of identity
To protect your privacy and that of others, you must provide evidence of your identity with this application or within 10 business days of making this application
in order for your application to be processed. If you are applying on someone’s behalf, both parties must provide evidence of their identities.
Applying:
by post — attach a certified copy of your identification document to this application form.
in person — produce the original identification document for the RTI officer to sight.
by email or fax — post or present a certified copy of the identification document to the relevant agency to which you are applying for information. (A certified
copy is considered valid if it is witnessed by a lawyer or notary public, a commissioner for declarations or a justice of the peace; or, in the case of a prisoner, a
corrective-services officer (refer to note below))
Note: Documents that provide sufficient evidence of identity include:
Current driver’s licence;
Identifying page of current passport;
Birth certificate;
Copy of a prisoner’s identity card certified by a corrective services officer; or
Statutory declaration of an individual who has known the applicant for at least one year.
(A declaration template can be downloaded at www.courts.qld.gov.au/Forms)
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© State of Queensland 2013
SPLES10786 V03 June 2013 Form 2IP
Declaration
Privacy Notice: The information you provide on this form will be used by the agency you are applying to, to deal with your application and assess your
application for amendment.
I declare that:
The information provided in this form is complete and correct
I have read the privacy notice
Where applicable, I have attached required supporting documents OR if I cannot attach them, I will provide them to the agency within 10 business
days of making this application.
I understand that it is an offence to give misleading information about my identity, and that doing so may result in a decision to refuse to process my
application.
Signature Date
............................................................................. .......... / .........../ ............
Date received RTI Ref / IP Ref
______ / _____ / ______ _________________
Satisfied as to Identity of Applicant ..............
No Yes Date ____ / _____/______
Identity Document Sighted ...........................
No Yes Date ____ / _____/______
Receiving Officer (print name) Decision Maker Assigned to Application (print name)
_______________________________________________________________ _________________________________________________________________
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