QUEENSLAND TITLES REGISTRY	REQUEST TO RECORD DEATH	FORM 4 Version 5

Land Title Act 1994, Land Act 1994 and Water Act 2000	Page 1 of 1

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.	Code
1. Deceased's name
2. Lot on Plan Description	Title Reference
3. Interest held by deceased
4. Applicant Given Names	Surname
Address for service of notices to the applicant: (for rates purposes etc)
5. Document(s) deposited Office copy of Death Certificate issued by the Registrar General of Births, Deaths & Marriages (Qld) or equivalent evidence from other jurisdictions
6. Authority of applicant The applicant is: * the surviving joint tenant of the land * the surviving trustee under Instrument No. * the attorney (appointed under section 56 of the Trusts Act) of the surviving trustee * the reversioner of the interest held by the deceased pursuant to clause of Lease/Standard Terms Document no. * the last surviving joint tenant and this application is made by the personal representative of the applicant as evidenced by the original Will deposited with Transmission by Death no. * delete if not applicable
7. Request In accordance with the particulars disclosed above, it is requested that this death be recorded. Witnessing officer must be aware of his/her obligations under section 162 of the Land Title Act 1994 signature full name qualification / / Witnessing Officer Execution Date Applicant's or Solicitor’s Signature
(Witnessing officer must be in accordance with Schedule 1 of Land Title Act 1994 eg Legal Practitioner, JP, C Dec) Note: A Solicitor is required to print full name if signing on behalf	Note: A Solicitor is required to print full name if signing on behalf of the Applicant and no witness is required in this instance