Instrument of Dealing – Mortgage Mineral Claims / Authorised Holding
Mining Act 1980 – Section 173Mineral Titles Act – Section 125 / Approved Form 27
Office Use Only
Dealing Number: D / Date Lodged / /
PARTICULARS OF MORTGAGOR
Full name of mortgagor 1:
Principal or residential address of applicant:
Postal address of applicant:
Australian Company Number:
Contact telephone number: ( )
Email Address:
Full name of mortgagor 2 (if applicable):
Principal or residential address:
Postal address:
Australian Company Number:
Contact telephone number: ( )
Email Address:
In the case of multiple parties, please attach a separate sheet showing the above details
SIGNATURE OF APPLICANT/S (or Agent/Representative) - Mortgagor
Mortgagor 1 Signature / Date / / /
Mortgagor 2 Signature (if applicable) / Date / / /
PARTICULARS OF MORTGAGEE
Full name of mortgagee:
Principal or residential address of applicant:
Postal address of applicant:
Australian Company Number:
Contact telephone number: ( )
Email Address:
SIGNATURE OF APPLICANT/S (or Agent/Representative) - Mortgagee
Mortgagee 1 Signature / Date / / /
Mortgagee 2 Signature (if applicable) / Date / / /
ADDRESS FOR NOTICES
Please nominate an address for all correspondence relating to this mortgage to be forwarded.
Full name of Agent/Contact:
Postal Address:
E-mail Address:
Telephone number:( )
NOTE: The above address is valid for THIS Instrument of Dealing transaction only.
DETAILS OF MINERAL TITLES - If space is insufficient, a schedule of affected titles must be attached.
Mineral Title Type / Mineral Title Number / Applicant/Title holder
FEES
All Dealing with Interest applications are to include the appropriate fees. A current schedule of fees and charges is available at NOTE: The amount specified in the schedule is applicable to each mineral title included in the “Details of Mineral Titles” above.
METHODS OF SUBMITTING APPLICATION AND PAYMENT DETAILS
Email application to
/ In Person
5th Floor Centrepoint Building
The Mall Darwin NT 0800
(Cash / Eftpos)
/ Post
Mail application to:
Department of Primary Industry and Resources
Mineral Titles Division
GPO Box 4550
DARWIN NT 0801
(Cheque payable to Receiver of Territory Monies)
/ Phone
Call (08) 8999 5322 to pay by Visa or MasterCard
Available 8am-4pm Monday to Friday (except public holidays)
/ Direct Deposit
Department of Primary Industry and Resources
BSB: 085-461
Account No: 932610008
Remittance advice must be emailed to the Department at using the dealing type and company name as reference
Before submitting your application:
Familiarize yourself with the relevant sections of the Mineral Titles Act and Regulations; and
Check if any guidelines made under the Act relate to this application.
Further information is available at or (08) 8999 5322
PRIVACY STATEMENT: The Department of Primary Industry and Resources (DPIR) is seeking information from you for the purpose of assessing your application under section 125 of the Mineral Titles Act (the Act). This information will be kept confidential except as required by law.
DPIR is required to keep a register of dealings with mineral titles interests under section 121 of the Act. Any person may obtain copies of this information under sections 121 and 128 of the Act, on payment of the prescribed fee.
DEPARTMENT OF PRIMARY INDUSTRY AND RESOURCESPage 1 of 3
12 January 2017