Person completing this form (You)

Given Name/s *

Surname *

Date of Birth *

Contact Number *

Email Address *

Residential Address *

Your relationship to the Other Person listed on this application *

Details of Other Person related to this Application

Other Person Given Name/s *

Other Person Surname

Of Address

Other Person Date of Birth

Other Person Date of Death (If applicable)

Reason for this Application

Council will not be able to process your application unless correct documentation is attached.

Please choose reason:

Notification of DeathNotification of Power of Attorney

Notification of Death

Please attach Certified Copy of Death Certificate

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Please attach Certified Copy of the Legal Will

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The Solicitor appointed for the estate is:

Solicitor Business Name

Solicitor Business Address

Solicitor Phone Number

Notification of Power of Attorney

Please attach Certified Copy of Power of Attorney document

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Please attach any other relevant document

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What changes do you require?

Please list changes required

Declaration

I have completed all required sections on this form. I declare that all the information provided on this form is true and correct and understand that it is an offence to provide false or misleading information.

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I acknowledge Wellington Shire Council's Privacy Statement.

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