Approved form under: Conveyancers Licensing Regulation 2015 (Clause 19 (5))

To
[Name of Licensed Conveyancer],
[address of conveyancer]
Re: [address of property subject to conveyancing]
I/We acknowledge that I/we have instructed you to hold money on my/our behalf.
I/We am/are aware that while you continue to hold my/our money I/we am/are entitled to receive from you a periodical statement of account in accordance with the provisions of clause 19 of the Conveyancers Licensing Regulation 2015.
I/We do not require you to furnish to me/us the periodical statement of account provided for by clause 19 (2)(b)(iii) of the Regulation.
☐	This waiver continues until [specify date]	unless revoked earlier in writing.
OR
☐	This waiver continues until revoked in writing.
Signature 1:	Print Name:
Date (dd/mm/yyyy)
Signature 2 (if applicable):	Print Name:
Date (dd/mm/yyyy)