SPLES10785 V07 June 2013 / Form 1 RTI-IP
Right to Information and Information Privacy Access Application
Right to Information Act 2009 (Section 24)
Information Privacy Act 2009 (Section 43)
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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Organisation / Company name (complete if you are making this application on behalf of an organisation or company)
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Postal address
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......................................................................................................................................................................... Postcode: .............................................
Preferred method of contact (Please indicate by numbering in order of preference, your preferred method of contact. If you choose email or post,
please also provide a contact telephone number. The agency may need to telephone you to clarify aspects of your application. Please include country
code and area code, where applicable).
Phone
Fax Mobile Email Post
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Please read the following information carefully before proceeding with your application.
It is recommended that you contact the RTI officer in the relevant agency for assistance and advice before completing and submitting this
application form.
The information you are seeking may be already available online, for purchase or by request:
Onlinea search of the relevant agency websites may locate the information you are seeking;
For purchase – agencies may offer documents for purchase (for example: birth certificates, transcripts of proceedings, spatial statistics);
By requestagencies may administratively release a range of information upon request.
If you wish to make a formal application to access documents under the Right to Information (RTI) Act 2009 or the Information Privacy (IP) Act 2009
the application must be submitted on this approved form.
This form is available at www.rti.qld.gov.au and on some agency websites.
RTI Act or IP Act?
You may apply under the IP Act if
all of the documents you are applying for contain your personal information
OR
you are acting on behalf of another person, and all of the documents contain that person’s personal information.
You should apply under the RTI Act in all other cases. If in doubt, contact the RTI officer of the agency to which you are applying.
Fees and charges
There is an application fee under the RTI Act, and you may also have to pay processing and access charges.
There is no application fee and and there are no processing charges under the IP Act, although you may have to pay access charges. For further
information about fees and charges, see www.rti.qld.gov.au or contact the agency youre applying to.
Great state. Great opportunity.
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Application Details
1. Which description most closely describes your application for access?
a. All of the documents I’m applying for contain my personal information OR I’m seeking access on someone else’s behalf, and all the
documents contain that person’s personal information – IP application, no application fee.
b.
Some of the documents I’m applying for do not contain my personal information OR I’m seeking access on someone else’s behalf, and
some of the documents do not contain that person’s personal information – RTI application, application fee payable.
c.
None of the documents I’m applying for contain my personal information OR I’m seeking access on someone else’s behalf, and none of
the documents contain that person’s personal information – RTI application, application fee payable.
2. Are you seeking access to information on someone’s behalf?
No
Yes
Persons family name Given name/s
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Please attach proof of your authorisation to act on the person’s behalf.
(for example: a client agreement if you are a solicitor or written authorisation from the person concerned).
3. If you ticked 1(b) or 1(c) only: are you seeking access for the use or benefit of another person, company or body?
(for example, a journalist applying for a media organisation)
No
Yes
4. If you answered yes to question (3) above, what is the name of the other person, company or body?
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5. Which agency/s are you applying to?
You must complete a separate form for each agency and there is a separate fee for each RTI application.
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6. Particular details:
Please provide specific and detailed information about the documents you are seeking, as this will help us process your application.
a. The subject matter of the documents you are seeking (e.g. the planning process for the Letter Z Program)
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b. The type of documents (e.g. internal memos, emails)
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c. The time period / date range you would like us to search within (e.g. September 2011 - June 2012)
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d. Relevant document reference numbers (if known)
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e. Where you think the documents may be located (e.g. facility, business area, unit, person)
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f. Any other details you believe will assist us in dealing with your application Note: Include additional information that the agency requires in the
space provided or as an attachment to your application (e.g. date of birth will assist in locating relevant les to distinguish you from someone with
the same name)
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7. Preferred access type (tick one):
Note: Your preferred access type may not be available. If you choose to access documents by email, CD, DVD or inspection, there will be no charge for this
access.
Inspect document/s Photocopy of document/s (charges may apply) Document/s sent to me by email
Copy of the document/s on DVD Copy of the document/s on CD
Note: Information that is released following an application under the RTI Act, and is not the applicant’s personal information, may be published in an
online disclosure log. See privacy notice.
8. Evidence of identity
If you are seeking access to documents that contain personal information either in relation to you or on behalf of another person, 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 seeking documents on someone’s behalf, both parties must provide evidence of their identities. (If you are not seeking any personal
information, you are not required to provide evidence of your identity.)
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 certied 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 ofcer. ‘refer note below’)
Note: Documents that provide sufcient 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
Statutory declaration of an individual who has known the applicant for at least one year
(A declaration template can be downloaded at www.court.qld.gov.au/forms).
9. Financial hardship
Concession card holders - Application for financial hardship must be made in writing to the relevant agency. If you hold a valid concession card, and
you are seeking a waiver of processing and access charges, you must show RTI officer your card (or attach a copy of the card to your application).
Note: Not all concession cards are accepted. Please contact the RTI ofcer to be sure your card qualies.
Non-Profit organisations - If you have financial hardship status, you must provide the RTI officer with a copy of the notice from the Office of the
Information Commissioner showing that financial hardship status has been granted.
Note: If you are a non-prot organisation and have sought nancial hardship status under the RTI Act, do not submit this application until you have advice from the Ofce
of the Information Commissioner about whether nancial hardship status has been granted. If nancial hardship status is granted, this status will remain current for
one year from the date of the Information Commissioner’s decision, unless there is a substantial improvement in your organisation’s nancial circumstances.
10. Credit card payments
Not all agencies can accept credit card payments. Please confirm with the agency youre applying to that it can accept credit card payments before
completing this section of the form (see next page).
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SPLES10785 V07 June 2013 / Form 1 RTI-IP
Date received RTI Ref / IP Ref
______ / _____ / ______ _________________
Application Fee Received ..............................
No Yes Date ____ / _____/______
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)
_______________________________________________________________ _________________________________________________________________
Office Use Only
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Declaration
Privacy Notice: The information you provide on this form will be used by the agency you have applied to, to deal with your application as set out in the
Right to Information Act 2009 or the Information Privacy Act 2009.
If you have applied under the RTI Act to a department or Minister only: Once the department or Minister receives your valid application, the date you
applied and what you are applying for will be published online in their disclosure log. If the department or Minister gives you access to a document,
and if the document contains no personal information about you, the document will be published online in the department or Minister’s disclosure
log, along with your name and, if another person, company or body will use or benefit from the documents sought, the name of that person, entity
or body. The department or Minister may remove some information from the document before it is published –for example, information that may be
defamatory.
If you have applied to an agency other than a department or Minister, documents which do not include your personal information may be published on
a disclosure log.
I declare that:
The information provided in this form is complete and correct
I have read the privacy notice
Where applicable, I have attached documents required for the purpose of this application
(e.g. evidence of identity, authorisation to act on another person’s behalf, evidence of nancial hardship status)
If I cannot attach any required copies of documents, I will provide them to the agency within 10 business days of making this application
I have included any relevant application fee/s (fees are based on the type of application, see section 1)
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
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Mastercard/Visa Authority
Expiry Date Card number Amount
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$ .....................................
Cardholder’s name Cardholder’s signature
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