QUEENSLAND TITLES REGISTRY	SURRENDER OF INDIGENOUS CULTURAL INTEREST	FORM 42 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. Dealing number of Indigenous Cultural Interest being surrendered	Lodger (Name, address, email & phone number)	Lodger Code (if any)
2. Lot on Plan Description	Title Reference
3. Indigenous Party

4. Surrender/Execution Surrender of Indigenous Cultural Interest *Full Surrender The Indigenous Cultural Interest in item 1 is surrendered. *Partial Surrender The Indigenous Cultural Interest in item 1 is surrendered in so far as relates to part of the Indigenous Cultural Interest area identified on the attached sketch plan. *delete if not applicable
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 Indigenous Party’s Signature (Witnessing officer must be in accordance with section 46 of Land Regulation 2009 eg Legal Practitioner, JP, C Dec)