Community Benefits Fund contribution form
Use this form to provide details of a contribution by a company to create a local fund to benefit a community affected by petroleum exploration or production.
Company details
Company name /Amount of contribution / $
Frequency of contribution/s /
Project name /
Title details (inc. PEL/PAL/PPLA number) /
LGA to benefit from the Fund /
In submitting this application, the above named company requests that an authorised Community Benefits Fund be declared for the above area and commits that the above contribution and subsequent contributions made to the Fund will follow the NSW Government’s Community Benefits Fund framework and operational procedures.
Signed on behalf of the company
This form should be signed by an authorised representative of the company.
Name /Position /
Date /
Signature /
Lodging this form
Lodge this form by email or mail it to Community Benefits Fund, Division of Resources and Energy, Locked Bag 5123, Parramatta NSW 2150.
If you have any questions about the Community Benefits Fund or this form, email .
PUB16/324 © State of New South Wales through the NSW Department of Industry, Skills and Regional Development. ABN: 72 189 919 072. The information contained in this publication is based on knowledge and understanding at the time of writing. However, because of advances in knowledge, users are reminded of the need to ensure that information upon which they rely is up to date and to check currency of the information with the appropriate officer of the NSW Department of Industry, Skills and Regional Development or the user’s independent advisor. Privacy statement: This information is collected by the Department of Industry, Skills & Regional Development (NSW Department of Industry) for the purposes of establishing the NSW Government Community Benefit Fund. The supply of this information is required by law. Information will be stored and managed in accordance with provisions under the Privacy and Personal Information Protection Act 1998. Except for purposes required by law, the information will not be accessed by any third parties in a way that would identify the person without the consent of that person.