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Declaration

Congestion Levy Form: Application for Registration as an Owner or Operator of a Car Park for the Congestion Levy

Fields marked with * are required

Collection statement

The information on this form is collected to enable you to comply with the requirements to apply to the SRO for registration of a car park in the levy area and to ensure that congestion levy is correctly assessed to the correct entity. If you do not provide this information, you may be required to pay penalty tax. The information collected may be used for the purposes of other SRO legislation. Where authorised by law to do so, we may disclose this information to other government agencies including the ATO, State and Territory revenue offices and law enforcement agencies. You can find out more about how we use and protect your information in our Privacy Policy on www.sro.vic.gov.au.

Declaration

I declare that I am authorised to make this declaration.

The information provided on this form and in any attached documents is complete and correct. I understand that penalties apply for giving false or misleading information or omitting information.

The Electronic Transactions (Victoria) Act 2000 establishes the regulatory framework for transactions to be completed electronically. This form requires you to complete an electronic signature via tick-box before lodgment. By ticking the box you indicate your approval of the contents of this electronic communication.

Date

Signature

Date (DD/MM/YYYY)

First name

Middle name(s)

Family name

Position (if applicable)

Organisation (if applicable)

Mobile number

Phone number

Email

Who are you?

Are you the owner or the operator of the car park?

An owner of the car park is a person who: •holds a freehold interest in the land on which the car park is situated, or •has been granted a lease or licence of Crown land on which the car park is situated. An operator of a public car park is a person who is not the owner of the premises on which the public car park is situated, but who operates the publiccar park under a lease, licence or other agreement. Note that both the operator and the owner of the premises on which that car park is located are jointly and severally liable to pay the congestion levy.

Owner

Operator

Owner

Congestion Levy Form: Application for Registration as an Owner or Operator of a Car Park for the Congestion Levy

Fields marked with * are required

As the owner, are you an:

Individual

Business

SRO customer number

Individual

First name

Middle name(s)

Family name

Business

Name of company

ABN

ACN

Contact person

First name

Middle name(s)

Family name

Contact

Mobile number

Phone number

Email

Operator

Congestion Levy Form: Application for Registration as an Owner or Operator of a Car Park for the Congestion Levy

Fields marked with * are required

As the operator, are you an:

Individual

Business

SRO customer number

Individual

First name

Middle name(s)

Family name

Business

Name of company

ABN

ACN

Contact person

First name

Middle name(s)

Family name

Contact

Mobile number

Phone number

Email

Postal address

Congestion Levy Form: Application for Registration as an Owner or Operator of a Car Park for the Congestion Levy

Fields marked with * are required

Postal address

Country

Australian address

What is the type of address?

Street

PO Box

Lot number

Floor/Level type

Floor number

Flat/Unit type

Unit number

PO Box number

Post office name

Lot number

Street number

Street name

Street type

Suburb/Town

State

Postcode

International address

Street address/Postal address

Suburb/Town

State

Postcode/Zipcode

Overseas Address

Authorised representative

Congestion Levy Form: Application for Registration as an Owner or Operator of a Car Park for the Congestion Levy

Fields marked with * are required

Do you want to nominate an authorised representative to act on your behalf?

Both the operator of a public car park and the owner of the premises on which it is located are jointly and severally liable to pay the congestion levy. You may, however, nominate the operator to lodge returns and receive all correspondence and assessments for the car park on your behalf. Please advise the operator that you have nominated them to act on your behalf.

Yes

No

If 'No' proceed to next section

The authorised representative is an:

Individual

Business

Individual

First name

Middle name(s)

Family name

Business

Name of company

ABN

ACN

Contact person

First name

Middle name(s)

Family name

Contact

Mobile number

Phone number

Email

Postal Address

Country

Australian address

What is the type of address?

Street

PO Box

Lot number

Floor/Level type

Floor number

Flat/Unit type

Unit number

PO Box number

Post office name

Lot number

Street number

Street name

Street type

Suburb/Town

State

Postcode

International address

Street address/Postal address

Suburb/Town

State

Postcode/Zipcode

Overseas Address

Declaration

Collection statement

Declaration

Who are you?

Owner

Individual

Business

Contact person

Contact

Operator

Individual

Business

Contact person

Contact

Postal address

Postal address

Australian address

International address

Authorised representative

Individual

Business

Contact person

Contact

Postal Address

Australian address

International address

Premises details

Property

Property address

Car park spaces

Owner

Additional owner

Owners/Additional owners

Contact person

Operator details

Contact person

Postal address

Australian address

International address

Nomination

Exemptions