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: *

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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 withServices Australia or the Department of Veterans Affairs. Your details may be checked regularly, to confirm ongoingeligibility. At any time, you have right to withdraw your consent by contacting Council.

I authorise:

Council to use Services Australia Confirmation eServices to perform a Centrelink/DVA enquiry of your Centrelink or DVA customer details and concession card status to enable Council to determine if I qualify for arebate.
Services Australia will provide the results of that enquiry to Council.

I understand that:

Confirmation eServices will disclose personal information to Council including my name, address, paymenttype, payment status and concession card type and status to confirm my eligibility for a rebate.
This consent, once signed, remains valid while I am a customer of Council unless I withdraw it by contacting Council or the department. I can get proof of my circumstances/details from Services Australia/ Departmentof Veterans Affairs and provide it to Council so my eligibility for a rebate can be determined.
If I withdraw my consent or do not alternatively provide proof of my circumstances/details, I may not be eligiblefor the rebate.

I have read and accepted the above consent

Name of person that is providing authorisation: *

Applicant Signature *

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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.