Applicationforcancellationofnegativenoticeornegativeexemptionnotice- Form 10-5
Forusebyapersonseekingtohaveanegativenoticeornegativeexemptionnoticecancelled.DisabilityServicesAct2006Section82.
UndertheDisabilityServicesAct 2006,aperson whohasbeenissuedwithanegativenotice
ornegativeexemptionnoticemayapplyto the Director-Generalforthecancellationofthe negativenoticeornegativeexemptionnotice andtheissueof apositivenoticeorpositive exemptionnotice.
Thisapplicationcannotbemadebyarelevant disqualifiedperson.
Thisapplicationcannotbemadelessthan2 yearsaftertheissueof acurrentnegativenotice/ negativeexemptionnoticeoranyprevious applicationforcancellationof anegativenotice/ negativeexemptionnoticeunless:
•thedecision to issuethenegativenotice/ negativeexemptionnoticewasbasedonwrong orincompleteinformation
•thenegativenotice/negativeexemptionnotice wasissuedbecausethepersonwasarelevant disqualifiedpersonandthepersonisnolonger arelevantdisqualifiedperson.
Howtocompletethisform:
•PartsA,B, C,F andthechecklistatthe endofthisformmustbecompletedbythe personseekingcancellationof anegative notice/negativeexemptionnoticeandissue ofapositivenotice/positiveexemptionnotice.
•PartsDandEmustbecompletedby aJusticeof thePeacewhosightsthe identification documents of the personseekingcancellationofanegativenotice/ negativeexemptionnoticeandissueof a positivenotice/positiveexemptionnotice
PRIVACYNOTICE
Thedepartmentiscollectingyourpersonal informationonthisformto assesswhether youareeligibleto haveanegativenoticeor anegativeexemptionnoticecancelled.Your personalinformationwillbeprovidedto the QueenslandPoliceServicefor thepurposeof obtainingcriminalhistoryandcertaininvestigative information.Yourpersonalinformationmayalso beprovidedtotheDirectorofPublicProsecutions, MentalHealthCourtandMentalHealthReview Tribunalasauthorisedunderthe Disability ServiceAct2006forthepurposesofobtaining additionalinformationrequiredto assessyour application.Yourpersonalinformationwillbe managedinaccordancewiththe Information PrivacyAct2009.
PARTA–Tobecompletedbythepersonseekingcancellationof anegativenotice/negativeexemptionnotice
Personaldetails:
Negativenotice/negativeexemptionnotice number:
Dateofissue:
Title:MrMrsMs
Gender: Familyname:
Givenname:
Middlename:(donotabbreviate)
Have youbeenknown byanyothernames?
NoYes
Ifyes,pleaseprovidedetailsbelow:
Othernamesused:
Circumstancesofnamechange:
Proofofnamechange:
(eg.maidenname,previous names,aliases. Provideproofof name change, eg. deed poll, marriage certificate).
Homeaddress: / Mailingaddress:(ifdifferentfromabove)
Contactnumber:
Mobile:Work:
Home:
Contactemail: Personal:Work:
Dateandplaceofbirth:
Date:City:State:Country:
ProofofidentityfromList1:
Type:Exp:Number:
State/Country ofIssue:(e.g.driver’slicense,passport)
ProofofidentityfromList2:
Type:Exp:Number:
(e.g.medicarecard)
Pleasedonotrecordcreditcardordebitcard numberandexpirydetails.
Forfurtherguidanceonwhichforms ofidentitymaybeusedpleasesee PartD
Note:Youmusttellthedepartmentwithin14daysifyour nameorcontactdetailsinthisapplicationchangeby completingform 10-2.
PARTB–Tobecompletedbythepersonseekingcancellationof anegativenotice/negative exemptionnotice
Hastherebeenachangeinyour circumstancessinceyournegativenotice/negativeexemptionnoticewasissued?
Yes No
Detailsofhowyourcircumstanceshave changedsinceyournegativenotice /negative exemptionnoticewasissued(attachadditional pagesif necessary). / Anythingelse youwishtosayinsupport ofyourapplication?
PARTC–Tobecompletedbythepersonseekingcancellationof anegativenotice/negative exemptionnotice
Declarationofpersonseekingcancellationofanegativenotice/negativeexemptionnoticeandissueofapositivenotice/positiveexemptionnotice
Please readthefollowingcarefullybefore signing:
•Ideclarethatthe informationthatI haveprovided in this form and the identification documents shown totheJusticeofthePeacearetrueand correct.
•Iconsenttothedepartmentobtainingacheck
ofcriminalhistory information (includingcharges andconvictions) andcertain investigative informationfrompolice,courts,prosecuting authorities and other bodies inQueenslandor elsewherein Australia includingtheDirector ofPublic Prosecutions,MentalHealthCourt and MentalHealthReviewTribunal. / •Iunderstandthat itcanbeanoffence under theDisabilityServicesAct2006tostate anythinginthis formor providematerialthatisfalseor misleading.
•Iunderstandtheprivacy noticeinthis form and Iconsenttothecollection, useanddisclosure of
mypersonalinformationinthemannerdescribed inthatnotice.
Signature: Date:
PARTD–To be completed by the Justice of the Peace who sights the identification documents of the personseekingcancellationof anegativenotice/negativeexemptionnotice
Proofofidentity
AJusticeofthePeacemustsighttheidentifying informationaboutthepersonseekingcancellation ofanegativenotice/negativeexemptionnoticeand
issueofapositivenotice/positiveexemptionnotice, andcertifythatthesedocumentshavebeensighted.
Theidentificationdocumentswhichmaybeused aresetoutintheDisabilityServicesRegulation 2017.
Thepersonseekingcancellationofanegative notice/negativeexemptionnoticeandissueof
apositivenotice/positiveexemptionnoticemustproducetwooriginalidentificationdocumentstoconfirmtheiridentity.Togetherthedocuments mustshow:
•fullname;
•dateofbirth;and
•signature.
TheJusticeofthePeacemustcertifyinPartEthatheorshehassighteddocumentsrelatingtoproof oftheidentityofthepersonseekingcancellationofanegativenotice/negativeexemptionnoticeand
issueofapositivenotice/positiveexemptionnotice. Atleastoneofthedocumentssightedmustshow theperson’ssignature. / Oneprimaryidentificationdocumentfrom
List1;and
Onesecondaryidentificationdocumentfrom
List2mustbesighted.
Ifthepersoncannotprovideanidentification documentfrom eitherList1orList2heorshe shouldcontacttheCriminalHistoryHotlineon 1800183690.
Note:
•Atleastonedocumentmustincludeasignature of the individual identified
•All identification documents sighted must be originals(photocopiesarenotacceptable).
•Whereanydocumentisinaformername, an original official document (eg. marriage certificate or change of name certificate)
showingthechangeofnamemustbesighted.
PARTD(cont’d) –To be completed by the Justice of the Peace who sights the identification documents of thepersonseekingcancellationofanegativenotice/negativeexemptionnotice
Pleasetickthe relevantboxfor the identification you have sighted
List 1 – Primary Identification Documents
Birth certificate
CurrentAustraliandriverlicencecontaining aphotographofthepersonseeking cancellationof anegativenotice/ negative exemptionnoticeandissueof apositive notice/ positiveexemptionnotice
Internationaltraveldocument,namely: acurrentpassport;or
anexpiredpassportthathasexpiredless than2yearsbeforetheexpiredpassport issighted;or
anothercurrentidentitydocument,having thecharacteristicsofapassportissued byagovernment,theUnitedNations
oranagencyoftheUnitedNationsforthe purposesof internationaltravel;or
anotherexpiredidentitydocument,having thecharacteristicsofapassportissued byagovernment,theUnitedNations
oranagencyoftheUnitedNationsforthepurposesofinternationaltravelthathasexpiredlessthan2yearsbeforethe documentissighted.
AnevidenceofAustralian citizenship document
Visaorentrypermitunderthe
MigrationAct1958(Cwth)
Currentconsularidentity documentcontaining aphotographofthepersonseeking cancellationof anegativenotice/ negative exemptionnoticeandissueof apositive notice/ positiveexemptionnotice
AdocumenttheDirector-Generalofthe department considers provides sufficient identification of the person seeking cancellationof anegativenotice/negative exemptionnoticeandissueof apositive notice/ positiveexemptionnotice / Pleasetickthe relevantboxfor the identification you have sighted
List2–SecondaryIdentificationdocuments
Recent(thelast12months)accountornoticeissuedbyapublicauthority
(forexample:councilratenotice;electricity accountstatement;gasaccountstatement,land valuationnotice,telephoneaccountstatement).
Recent(thelast12months)documentevidencingelectoralenrolment.
IdentificationcardissuedbyCommonwealth oraStateasevidenceoftheperson’s entitlementtoafinancialbenefit(forexample: Commonwealthseniorshealthcard,health carecard,medicarecard,pensioner concessioncardandrepatriationhealthcard).
Currentaccountcardorcurrentcreditcard fromabank/buildingsociety/creditunion (withnameandsignature).
Passbookoraccountstatementissuedby abank/buildingsociety/credituniondated inthelast12months.
PARTE –To be completed by the Justice ofthe Peace who sights the identification documents of the
personseekingcancellationof anegativenotice/negativeexemptionnotice
CertificationbyJusticeofthePeace
IcertifythatIhavesighted,inaccordancewith theDisabilityServicesAct2006,oneprimary identification document and one secondary identification document proving the identity of the personseekingcancellationofanegativenotice/ negativeexemptionnoticeandissueof apositive / notice/positiveexemptionnoticeandhavechecked theirpersonalinformationonthisform againstthe originaldocuments.
Signature: Date:
CHECKLIST–Tobecompletedbythepersonseekingcancellationof anegativenotice/negative exemptionnotice.Pleaseindicatethat allsectionsof aform havebeencompletedandallrelevant documentationhasbeenattached.
PartsA,B,CandFhavebeencompletedbythe personseekingthecancellationofanegativenotice/negativeexemptionnoticeandissueof apositivenotice/positiveexemptionnotice(required).
PartsDandEhavebeencompletedbyaJusticeofthePeace(required).
Returnto:
DepartmentofCommunities,DisabilityServices and Seniors
POBox10179,BRISBANEADELAIDESTREETQLD4001 OR
Phone:1800183690/Fax: 0734056422
PARTF –Tobecompletedbythepersonseekingcancellationof anegativenotice/negativeexemptionnotice
Paymentdetails
Thisapplicationisnotconsideredlodgedunlessitisaccompaniedbytheprescribedfee.Thissectionmustbecompletedunlessthisapplicationismadeonbehalfof avolunteer.Pleasenotethattheapplicationfeeis non-refundableandsubjectto change.
An$92.20 feeisrequiredforpaidemployees.
Pleaseselectoneofthefollowingpaymentmethods:
ChequeMoneyOrderCheque/MoneyOrderpayableto:
DepartmentofCommunities,DisabilityServices and Seniors
ABN25791185155
Creditcard–completepaymentonlineat Pleasecompletethefollowingdetails:
Receiptnumber Datepaymentmade
Toavoiddelaysinprocessing,please attachacopyof thereceiptwhenpayingbycreditcardandensureall
applicantdetailsenteredonlinematchthoserecordedonthisform.
Whoisthepaymentreceipttobemadeoutto? / Whereisthereceiptto besent(email/post)?