Sch 1AForm of nomination of object integral or additional land to a registered or nominated place

Schedule 1A—Form of nomination of object integral or additional land to a registered or nominated place

Sections 27A(3) and 27B(3) of the Heritage Act 2017

Regulations 5A and 5B

1. Location of place

Location selection method

If the place is not yet registered, the nomination reference number (provided by Heritage Victoria when the initial nomination of the place was lodged):

(If you cannot find your reference number, please contact Heritage Victoria).

Place name:

2. Nominator details

Details of owner or government asset manager of place or object (if known)

If the nominator is not the owner or the government asset manager (or acting on behalf of the owner or the government asset manager) details of the owner or government asset manager of the place:

*Body corporate name:/*organisation name:/*government asset manager:

Is common property included in this place? *Yes/*No

3. Nomination details

What do you want to nominate?

*Additional land to a place/*objects integral to a place:

What are the reasons for lodging this nomination?

Is there a threat to the place?

*Yes/*No/*Don't know

If yes, what is the threat?

If nominating additional land to a place

• Is the additional land of significance? *Yes/*No

If yes, please explain why:

• Is the additional land needed as a buffer? *Yes/*No

If yes, please explain why:

Note: For example, the State-level cultural heritage significance of the place would be substantially less if the additional land or any part of the additional land which is or has been used in conjunction with the place were developed; or the additional land surrounds the place and is important to the protection or conservation of the place or contributes to the understanding of the place.

Describe the additional land you want to include

Describe the additional land.

(You may reference title details of the land, or attach an extent diagram showing the boundaries of the land or physical landmarks.)

If adding objects integral to a registered or nominated place

Please provide information on the object or collection of objects and explain why the objects are integral to the cultural heritage significance of the place.

If nominating additional land

Is the additional land located entirely on Crown land? *Yes/*No