Pensioner Concession Application Form

PENSIONER CONCESSION APPLICATION FORM

If joint owners are eligible for a pensioner concession, a separate form will need to be completed by each owner to receive the maximum rebate, otherwise only a partial rebate will be granted. For further information or questions regarding this form, please contact Council via 9911 6555.

Please confirm what year (or part of the year) commencing from 1 July you are applying for a pensioner concession *e.g. 2022

Applicant Details

Property ID No: *(please refer to Councils Rates and Charges Notice)

Surname *

First Name *

Address *

Suburb *

Postcode *

Contact number: *

Email *

Pension concession card number: *

Date of grant *

Pensioner Concession card: *

Browse

Please upload a photo of your card, clearly showing all details

Questionnaire Part 1

Have you claimed a pensioner rebate for any other property in the last 12 months? *

YesNo

Please provide the address of the other property: *

Have you claimed a pensioner concession on any other property this year? *

YesNo

The property for which I am claiming has been my sole/principal place of living since: *

Are you the sole owner of the property? *

Yes No

If NO, I am liable for the payment of rates and charges on this property, together with others as listed below.

Provide details of all other owners including your spouse or de facto partner should be listed:Please provide: Full name, If they are a PCC holder, Pension number, Date of grant, Relationship to you, if they are a resident of the property and % of ownership

Applicant declaration

The information contained in this application form and any information requested for the purpose of assessing eligibility for a pensioner concession is required under the Local Government Act 1993 and the Local Government (General) Regulation 2005.

By submitting this form, you declare that the information provided is true and correct and that you are the person making this application. If you make a false statement in an application, you may be guilty of an offence and fined up to $2,220.

Signature: *

Draw signature|Type signatureClear

Date: *

Applicant consent

The information provided on this form is private and confidential and Council must not disclose the information to anyperson or body, if it is not directly related to the purpose for which the information was collected. If you have a complaintabout the use of your personal information, contact Council’s Public Officer. The information contained or referred toin this application form may be corrected and updated by you, by contacting Council.

Please read the conditions and sign below to confirm your consent to Council checking your concession eligibility with Services Australia or the Department of Veterans Affairs. Your details may be checked regularly, to confirm ongoing eligibility. At any time, you have right to withdraw your consent by contacting Council.

I authorise:

The City of Canada Bay to use Centrelink Confirmation eServices to perform a Centrelink enquiry of my customer details and concession card status in order to enable the business to determine if I qualify for a concession, rebate or service.
Services Australia to provide the results of that enquiry to The City of Canada Bay.

I understand that:

Services Australia will disclose personal information to The City of Canada Bay including my <name/address/concession card status/payment status> to confirm my eligibility for pensioner Council rates rebate.
This consent, once signed, remains valid while I am a customer of The City of Canada Bay unless I withdraw it by contacting The City of Canada Bay or Services Australia.
I can get proof of my circumsances/details from Services Australia and provide it to The City of Canada Bay so they can determine my eligibility for pensioner Council rates rebate.
If I withdraw my consent or don't alternatively provide proof of my circumstances or details, I may not be eligible for the pensioner Council rates rebate provided by The City of Canada Bay.

I have read and accepted the above consent

Name of person that is providing authorisation: *

Applicant Signature *

Draw signature|Type signatureClear

Date signed *

Additional Information:

Council will determine your eligibility to receive a rebate of up to $250 on your rates account. You may also be eligible to receive a discount off your annual sewerage charges, if Council provides these services. Alternatively, if Council does not provide these services, contact your water/sewer serviceprovider for more information.

Eligibility:

• Holders of the PCC (Pensioner Concession Card);

• Holders of a gold card embossed with ‘TPI’ (Totally Permanently Incapacitated);

• Holders of a gold card embossed with ‘EDA’ (Extreme Disablement Adjustment);

• War widow or widower or wholly dependent partner entitled to the Pensioner Concession Card*.

* If you are a war widow or widower or wholly dependent partner but do not have a Pensioner Concession Card, you should contact the Department of Veterans’ Affairs (DVA) to test your eligibility for the DVA income support supplement. Eligibility is subject to an income and assets test. Holders of cards other than those listed above are not eligible for theconcession. For assistance from the DVA call 133 254.