Request for Environmental Offset Protection Area declaration

(This is an approved form under Section 92 of the Environmental Offsets Act 2014)

This form must be completed withthe consent of all land owners applying to declare land as an environmental offset protection area in accordance with Section 30 of the Environmental Offset Act 2014. This form must be submitted to the Department of Environment and Science via the Offsets team (). Schedule 1 Declaration details and Schedule 2 Declaration signatures must be completed.

SCHEDULE 1 – DECLARATION DETAILS
PART A – MANDATORY SUPPORTING DOCUMENTATION
Please ensure that the following documents are attached to this request for declaration:
☐environmental offset agreement; and
☐offset delivery plan.
PART B – PRIMARY CONTACT PERSON DETAILS
Primary contact (All general correspondence will be directed to this person.)
The primary contact person must be one of the following persons:
  • the owner of the land;
  • an owner of the land who has obtained written consent from all other owners of the land to act on behalf of the owners of the land to make this application; or
  • a person who has obtained written consent from all the owner(s) of the land to act on behalf of the owner(s) to make this application.
Contact name / Click here to enter text. /
Postal address of contact / Click here to enter text. /
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Suburb / Click here to enter text. /
State / Click here to enter text. / Postcode / Click here to enter text. /
Country / Click here to enter text. /
Primary contact number / Click here to enter text. /
Secondary contact number (non-mandatory requirement) / Click here to enter text. /
Fax number (non-mandatory requirement) / Click here to enter text. /
Email (non-mandatory requirement) / Click here to enter text. /
Authority reference where offset impacts were authorised (e.g. EPPG0123456, SDA-012-3456) / Click here to enter text. /
PART C – DECLARATION AREA
Extent of properties
I seek declaration over the following parcels of land (either in full or in part):
Lot / Plan / Extent sought under declaration request
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Spatial information
Digital data representing the extent of the environmental offset protection areamust be provided with this application (shapefile or kml formats only).
If the land* proposed for an environmental offset protection area covers only part of a land parcel or extends past the boundary of a single land parcel, map coordinates will be required in order to accurately reflect the extent of the declared area. Two options are provided below – please fill in one of these.
Explanatory Note: In accordance with the Environmental Offset Act 2014 land includes water*
Option 1: Mapping co-ordinates (UTM)
Easting / Northing / Zone reference / Datum
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Attach table with additional rows as required.>
Option 2: Map co-ordinates (Geographic co-ordinates)
Latitude (decimal degrees) / Longitude (decimal degrees) / Datum
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Attach table with additional rows as required.>
PART D – LANDHOLDER DECLARATION
All owners of each parcel of land proposed to be included as all or part of an environmental offset protection area must fill out Schedule 2, Part A of this document. Extra pages may be attached if there are additional owners. All signatures must be witnessed in accordance with Schedule 1 of the Land Title Act 1994 e.g. Legal Practitioner, Justice of the Peace, Commissioner for Declarations, etc.
PART E – INTEREST HOLDERS IN PROPOSED ENVIRONMENTAL OFFSET PROTECTION AREA
Each person with an interest in the land (other than the owners of the land) over which the environmental offset protection area may be declared must provide consent to the declaration in Schedule 2, Part B of this document. Extra pages may be attached if there are additional registered interests. All signatures must be witnessed in accordance with Schedule 1 of the Land Title Act 1994 e.g. Legal Practitioner, Justice of the Peace, Commissioner for Declarations, etc.
A person with an interest in the proposed environmental offset protection area means:
-a person with a registered interest, under the Land Act 1994 or the Land Title Act 1994, in the land area; or
-if the land is subject to a lease, mining interest, geothermal tenure or GHG authority – the lessee, interest holder, tenure holder or authority holder;
-if the land in the area is forest entitlement area, State forest or timber reserve under the Forestry Act 1959 or land prescribed under a regulation for the purpose of identifying a person with an interest in land– the chief executive of the department in which the Forestry Act 1959 is administered.
A person’s interest in the land determined under a lease, licence or other authority granted under a law, may be affected by the environmental offset agreement associated with the declaration of the environmental offset protection area.
An EOPA does not affect Native Title rights that may exist over an area that is declared. If Native Title possibly exists over the land subject to the EOPA, consultation should be undertaken with the relevant groups and evidence of the group’s support (or otherwise) of the EOPA should be attached to this application. Note that Native Title claimants may have a registered interest and in that case should be a signatory to Schedule 2 as per above. Further information about Native Title can be obtained from the Department of Natural Resources, Mines and Energy (
Has the administering agency that granted the lease, licence or other authority endorsed the environmental offset agreementand the related offset delivery plan?


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PART F – DECLARATION STATEMENT
I, the primary contact, declare that the information provided in this form is true and accurate. The information provided for the proposed environmental offset protection area is consistent with the agreed delivery arrangement.
Applicant’s name / Click here to enter text. / Signature
Witness / Click here to enter text. /
Qualification of witness
(e.g. Legal Practitioner, Justice of the Peace, Commissioner for Declarations etc) / Click here to enter text. /
Signature of witness / Date signed / Click here to enter text. /
PART G - INFORMATION PRIVACY STATEMENT
The Department of Environment and Science (DES) is collecting the information in this form and any attachments to process a request for the chief executive to declare an environmental offset protection area in accordance withSection 30 of the Environmental Offsets Act 2014. The consideration of this request may involve consultation, and if so, details of this request and any attachments may be disclosed to relevant third parties. Personal information will not otherwise be disclosed outside the department unless required or authorised by law.

Office use only ------

Date received / Receiving officer / Reference number
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SCHEDULE 2 – DECLARATION SIGNATURES
PART A – LANDHOLDER DECLARATION
All owners of each parcel of land proposed to be included as all or part of an environmental offset protection area must sign and date this section.
Explanatory Note: In accordance with the Environmental Offset Act 2014 an owner, of land, includes the following—
(a) for freehold land—the person recorded in the freehold land register as the person entitled to the fee simple interest in the land;
(b) for land held under a lease—the person who holds the lease;
(c) for trust land under the Land Act 1994—the trustees of the land;
(d) for Aboriginal land under the Aboriginal Land Act 1991—the persons to whom the land has been
transferred or granted;
(e) for Torres Strait Islander land under the Torres Strait Islander Land Act 1991—the persons to whom the land has been transferred or granted;
(f) for a State-controlled road under the Transport Infrastructure Act 1994—the chief executive of the
department in which that Act is administered;
(g) for a road controlled by a local government under the Local Government Act 2009—the local government;
(h) for other land prescribed under a regulation—the entity prescribed under a regulation for the land.
Statement
I/We
  • consent the primary contact to submit the declaration and receive general correspondence relating to this application;
  • request the declaration of an environmental offset protection area under the Environmental Offsets Act 2014 over all or part of the land as outlined in Part B of the application;
  • consent to the collection and use of the personal information in this form for the purposes of assessing this request for an environmental offset protection area under the Environmental Offsets Act 2014;
  • solemnly and sincerely declare that the information provided is true and correct to the best of my/our knowledge and I/we make this solemn declaration conscientiously believing the same to be true; and
  • understand that all information supplied on or with this application form may be disclosed publicly in accordance with the Right to Information Act 2009 and the Evidence Act 1977;
  • understand that the department may request evidence that the authorised representative is duly authorised to sign the declaration on the owner’s behalf; and
  • consent to allow access to the land by the department and its agents or subcontractors for the purposes of delivering the offset in accordance with the environmental offset agreement and offset delivery plan.
Lot and Plan of EOPA / Click here to enter text. /
Owner / Click here to enter text. /
Authorised representative of the owner (if applicable) / Name: Click here to enter text. / Position: Click here to enter text.
Postal address of owner / Click here to enter text. /
Signature of owner or authorised representative / Date signed / Click here to enter text. /
Witness / Click here to enter text. /
Qualification of witness
(e.g. Legal Practitioner, Justice of the Peace, Commissioner for Declarations etc) / Click here to enter text. /
Signature of witness / Date signed / Click here to enter text. /
PART B -INTEREST HOLDERS IN PROPOSED ENVIRONMENTAL OFFSET PROTECTION AREA
Each person with an interest in the land (other than the owners of the land) over which the environmental offset protection area may be declared must provide consent to the declaration.
Declaration area as described in Part D / Registered interest / Registered interest holder name
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Consultation
Describe any consultation undertaken with parties other than interested persons.
Interested party / Outcome of consultation
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All parties who have an interest in the land to which the environmental offset protection area relates must sign and date this section. If there is a mortgage associated with any parcel of land to be declared, the signature of an authorised person of the financial institution is required.
Statement
I/We
  • consent to the declaration of an environmental offset protection area under the Environmental Offsets Act 2014 as outlined in Part B of this application;
  • consent to the collection and use of the personal information in this form for the purposes of assessing this request for an environmental offset protection area under the Environmental Offsets Act 2014;
  • consent for the administering authority to update the land title(s) on behalf of the landholders by submitting an application to the Land registrar;
  • solemnly and sincerely declare that the information provided is true and correct to the best of my knowledge and I make this solemn declaration conscientiously believing the same to be true; and
  • understand that all information supplied on or with this application form may be disclosed publicly in accordance with the Right to Information Act 2009 and the Evidence Act 1977.
Registered interest e.g owner, lessee, mining interest, tenure holder, authority holder. / Click here to enter text. /
Authorised representative of registered interest holder (if applicable) / Name: Click here to enter text. / Position: Click here to enter text.
Signature of registered interest or authorised representative (if applicable) / Date signed / Click here to enter text. /
Witness / Click here to enter text. /
Qualification of witness
e.g Legal Practitioner, Justice of the Peace, Commissioner for Declarations etc. / Click here to enter text. /
Signature of witness / Date signed / Click here to enter text. /

Page 1 of 6 • CSS/2018/4205 • Version 3.01 • Effective: 18 OCT 2018