[Your name]
[A safe postal address]

[Date]

[Landlord’s or agent’s name]
[Landlord’s or agent’s address]

Dear  . . . [landlord/agent/co-tenant]

Domestic Violence Termination Notice
(Division 3A Residential Tenancies Act 2010)

As I am in domestic violence circumstances, I give notice that I shall cease to be a tenant of  

[Premises address] 

on 

[A date on or after this notice is given]

by serving this notice on you and vacating the premises.

Yours sincerely

[Your name / signature]

Attach one of the following:
	▪	Declaration by a Competent Person; or
	▪	Provisional, interim or final Apprehended Domestic Violence Order (ADVO); or
	▪	Certificate of conviction of the domestic violence offender; or
	▪	Family law injunction.