QUEENSLAND TITLES REGISTRY	INDIGENOUS CULTURAL INTEREST	FORM 41 Version 1

Land Act 1994	Page 1 of 1

Dealing Number
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.
1. Registered Lessee	Lodger (Name, address, email & phone number)	Lodger Code (if any)
2. Lot on Plan Description	Title Reference
3. Indigenous Party

4. Execution The Indigenous Cultural Interest is in terms of the attached agreement. Witnessing officer must be aware of his/her obligations under section 311 of the Land Act 1994 signature full name qualification / / Witnessing Officer Execution Date Registered Lessee’s Signature (Witnessing officer must be in accordance with section 46 of Land Regulation 2009 eg Legal Practitioner, JP, C Dec) signature full name qualification / / Witnessing Officer Execution Date Registered Lessee’s Signature (Witnessing officer must be in accordance with section 46 of Land Regulation 2009 eg Legal Practitioner, JP, C Dec)