QUEENSLAND TITLES REGISTRY Land Title Act 1994, Land Act 1994, and Water Act 2000	REQUEST TO REGISTER WRIT / WARRANT OF EXECUTION	FORM 12 Version 5 Page 1 of [Insert Total Number of Pages]
Dealing Number	Lodger (Name, address, E-mail & phone number)	Lodger
OFFICE USE ONLY Privacy Statement Collection of information from this form is authorised by legislation and is used to maintain publicly searchable records. For more information see the Titles Queensland website.	Name: Insert Name of Lodger Postal Address: Insert Address of Lodger Email: Insert email Address of Lodger Phone Number: Insert Phone Number of Lodger	Code Insert Lodger Code
1. Lot on Plan Description Lot Insert Lot Number On Select Plan Type Insert Plan Number	Title Reference Insert Title Reference
2. Registered Proprietor(s)/State Lessee(s) whose interest is bound or affected Insert Name of Registered Proprietor(s)/Lessee(s)
3. Name of Applicant (the Enforcement Creditor) Insert Name of Applicant including A.C.N (if applicable)	4. Particulars of Writ/Warrant Writ/Warrant of Execution No. Insert Number of Insert Year of Writ/Warrant Court / Registry: Select Court / Registry Enforcement Debtor – Insert Name of Debtor Expiry Date - Click or tap to enter a date.
5. Request and Execution by the Applicant The applicant requests that the attached Writ / Warrant of Execution be registered over the land described in Item 1. The applicant confirms that: The Writ/Warrant has not been wholly satisfied. An office copy of the Writ/Warrant is attached. The Registered Proprietor/State Lessee of the interest is identical with the Enforcement Debtor in the Writ/Warrant. It is requested that the particulars of the Writ/Warrant be registered. The applicant is authorised to make this request. Signature Signer Name Insert Signer Name Signer Authority Select Signer Authority Execution Date Click or tap to enter a date. Signature Signer Name Insert Signer Name Signer Authority Select Signer Authority Execution Date Click or tap to enter a date.

The Court order must be current at the time of lodgement. If the writ / warrant has been extended, the new expiry date must be inserted.

Office copy means the actual certificate or document issued from the issuing authority (including court) and certified or otherwise authenticated by the authority where this is the authority’s practice, or a certified copy of the original certificate or document. For further guidance refer to Part [60-1030] of the Land Title Practice Manual.