The Property:

1. There is a proposal to sell the rented premises AND I/we have engaged an agent to sell the rented premises OR have prepared a contract of sale.
YesNo

2. A mortgagee is taking action for possession of the rented premises and has commenced a proceeding to enforce a mortgage over the rented premises.
YesNo

3. I/we are the owner/s of the rented premises.
YesNo

I/we are not the owners of the rented premises but have a right to let the rented premises.
YesNo

4. The rented premises are supplied with electricity from an embedded electricity network**YesNo
**Embedded electricity network means a privately owned electricity network that serves more than one customer and that connects to a distribution or transmission system in the national electronic grid through a parent connection point.)

If “Yes”, I/we provide the following information about the operator:

ABN of the operator:

Trading name of the operator:

Phone number of the operator:

Website of the operator:

Other contact details of the operator:

Electricity tariffs for the premises:

Other fees and charges when purchasing electricity:

Information about tariffs, fees and charges can be obtained from:

5. The rented premises or common property have been the location of a homicide in the last 5 years.
YesNoDon’t know

6. The rental premises comply with the rental minimum standards. **
YesNo
(**Rental minimum standards are specified in Schedule 4 of the Residential Tenancies Regulations 2021. A copy of the Schedule can be found at the end of this document.)

7. I/we have received a repair notice in the last 3 years, relating to mould or damp in the premises caused by or related to the building structure**
YesNo
(**Note: This question only needs to be answered if you are completing this form on or after 31 December 2021)

8. The date of the most recent gas safety check is:


(*If there are no gas appliances at the premises write “not applicable”)

The date of the most recent electrical safety check is:

The date of the most recent pool barrier compliance check is:

(*If there is no pool or spa required to have a barrier at the premises write “not applicable”)

9. There are NO outstanding recommendations for work to be completed from the gas safety check?
AgreeThe outstanding recommendations for work are:

Not Applicable
( *Note: “Not applicable” should only be selected if there are no gas appliances at the premises.)

10. There are NO outstanding recommendations for work to be completed from the electrical safety check?
agreeThe outstandings recommendations for work are:

No

11. The rented premises is a registered place?**
YesNo
(**Registered place means a place included in the Victorian Heritage Register under the Heritage Act 2017)

12. The rented premises has been contaminated because of prior use of the rented premises for the trafficking or cultivation of a drug of dependence in the last 5 years?
YesNoDon’t know

13. The rented premises has friable or non-friable asbestos based on (identified by) an inspection by a suitably qualified person?
YesNoDon’t know

14. The rented premises is to be affected** by a building or planning application that has been lodged with the relevant authority?
YesNoDon’t know
(**affected is not limited to the rented premises and a rented premises may be affected by a building or planning
application for a neighbouring or nearby property.)

15. The rented premises or common property is the subject of any notice, order, declaration, report, or recommendation issued by a relevant building surveyor, municipal building surveyor, public authority or government department relating to any building defects or safety concerns associated with the rented premises or common property at the time of disclosure**?
YesNoDon’t know

If “Yes”, I/we provide the following as a description of the notice, order, declaration, report or recommendation (or attach the notice, order, declaration, report or recommendation):

Description:

(**Example: Any building notices or orders, reports or recommendations issued by the Victorian Building Authority, local councils, relevant building surveyors, or municipal building surveyors that relate to any building defects or safety concerns such as the presence of combustible cladding, water leaks or structural issues affecting the rented premises or common property.)

16. There is a current domestic building work dispute under the Domestic Building Contracts Act 1995 which applies to or affects the rented premises.
YesNo

17. There is a current dispute under Part 10 of the Owners Corporations Act 2006** which applies to or affects the rented premises.
YesNoDon’t know
**Part 10 of the Owners Corporations Act 2006 describes the handling of disputes)
( *Note: The “Not applicable” option should only be selected if there is no Owners Corporation.)

18. The rented premises is subject to an owners’ corporation?
YesNo

If “Yes” I/we have attached a copy of the owners’ corporation rules applicable to the rented premises.
YesNo

19. I/we have checked all questions to ensure that all have been answered and that the answers are correct?
YesNo

Signature/s of the residential rented provider/s

Date of this disclosure statement