Pensioner Concession Application Form

APPLICATION TO CITY OF CANADA BAY FOR A PENSIONER CONCESSION

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.

Property ID: *(Please refer to Council's Rates and Charges Notice)

Surname *

First Name *

Concession Card Type *

Concession Card Number: (Customer Reference Number [CRN], Veteran File Number, DVA Unique Identification Number [UIN]) *

Date of Grant of Concession Card *

Concession Card: *

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

Phone: *

Email *

Property Address *

Suburb *

Postcode *

Is this your sole / principal place of living? *

When did you move into the property? *

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

YesNo

If Yes, please provide the address of the other property:

Are you the sole owner of the property? *

Yes No

If NO, I am listed on the Certificate of Title as a co-owner of the property, together with others as listed below.

If more than one other co-owner please list the name of each co-owner and their relationship to you: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 the share percentage of ownership

Declaration

I declare that the information provided in this form is true and correct and that I am the person making this application. I understand that providing information that is false or misleading is an offence, the maximum penalty for which is 200 penalty units or 2 years imprisonment or both.

I have read and accept this Declaration *

Privacy notice

When you submit this form, the information you provide on it is being collected and held by City of Canada Bay (Council), 1A Marlborough St Drummoyne NSW 2047, to assess your eligibility to receive a pensioner concession regarding the payment of charges and/or rates under the Local Government Act 1993 (NSW) (LG Act) and associated regulations.

The information provided on this form is private and confidential. Council will not disclose the information to any person or body if it is not directly related to the purpose for which the information was collected, unless disclosure is required under a relevant law. The supply of your information is voluntary, but if you choose not to provide information requested on this form and/or evidence that you meet the definition of an ‘eligible pensioner’ under the LG Act and associated regulations (see below), it may affect the outcome of your application for a pensioner concession.

If you would like more information on privacy, wish to correct or update your personal information provided, or have a complaint about the use of your personal information, contact Council’s Public Officer.

Consent to obtain evidence to assess your application for a pensioner concession

To assist City of Canada Bay with assessing your eligibility for a pensioner concession, it seeks your consent to use Centrelink Confirmation eServices to perform a Centrelink and/or Department of Veterans’ Affairs (DVA) enquiry, and obtain its results, regarding your Centrelink or DVA customer details and concession card status. Your details may be checked regularly, to confirm ongoing eligibility. At any time, you have a right to withdraw your consent by contacting City of Canada Bay or Services Australia.

Please read the following and then select a tick box below regarding your consent.

I *

authorise:

City of Canada Bay to use Centrelink Confirmation eServices to perform a Centrelink/DVA enquiry of my Centrelink or DVA customer details and concession card status to enable City of Canada Bay to determine if I qualify for a pensioner concession.
Services Australia to provide the results of that enquiry to City of Canada Bay.

I understand that:

Services Australia will disclose my personal information to City of Canada Bay including my <name, address/postcode, payment type, payment status and concession card type and status> to confirm my eligibility for a pensioner concession.
If I withdraw my consent or do not alternatively provide proof of my circumstances or details, I may not be eligible for the pensioner concession provided by City of Canada Bay.
City of Canada Bay will disclose my personal information received from the result of the Centrelink/DVA enquiry to the Audit Office of New South Wales for the purposes of auditing/assurance.
This consent, once signed, remains valid while I am a customer of City of Canada Bay unless I withdraw it by contacting City of Canada Bay or Services Australia. I can get proof of my circumstances or details from Services Australia or DVA and provide it to City of Canada Bay so they, City of Canada Bay, can determine my eligibility for a pensioner concession.
I confirm that the electronic signature in this consent represents my signature.
I consent to signing the form electronically and I confirm that my signature is legally binding.

Please select one of the following: *

Yes, I have read and understand the above and give my authorisation.No, I do not agree to the above and do not give my authorisation. Instead, I will provide a Proof of Concession Eligibility Letter from Centrelink or DVA.

Signature: *

Draw signature|Type signatureClear

Date: *

Additional Information

Council will determine your eligibility to receive a pensioner concession of up to $250 off your annual rates and/or charges. You may also be eligible to receive up to $87.50 on your annual water charges and up to $87.50 off your annual sewerage charges, if Council provides these services. Alternatively, if Council does not provide these services, contact your water/sewer service provider for more information.

Eligibility:

Holders of the PCC (Pensioner Concession Card)*;
Holders of the DVA Veteran Gold Card embossed ‘TPI’ (Totally & Permanently Incapacitated);
Holders of the DVA Veteran Gold Card embossed ‘EDA’ (Extreme Disablement Adjustment).

Holders of cards other than those listed above are not eligible for the concession.

* If you are a War Widow or Widower or Wholly Dependent Partner and do not have a Pensioner Concession Card, you could contact the DVA to test your eligibility for the DVA Income Support Supplement which attracts a PCC. Eligibility is subject to an income and assets test. For assistance from the DVA call 1800 VETERAN (1800 838 372).