Application to QPRC for a Pensioner Concession Rates Rebate

This concession form is only for residents of the Queanbeyan-Palerang Regional Council area.

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.

Property number *

Name *

Concession Card Type *

Concession Card Number *

Date of grant of Concession Card *

Contact phone (during business hours) *

Email address *

Property Address *

Street address *

City *

State *

Postcode *

Is this your sole / principal place of living *

YesNo

When did you move into the property? *

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

YesNo

Please provide the address of the other property

Are you the sole owner of the property? *

YesNo

Who else owns a share? If more than one other co-owner please list the name of each co-owner and their relationship to you.

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 Queanbeyan-Palerang Regional Council (Council), 257 Crawford Street, Queanbeyan, 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 Queanbeyan-Palerang Regional Council 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 Queanbeyan-Palerang Regional Council or Services Australia.

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

I authorise:

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

I understand that:

Services Australia will disclose my personal information to Queanbeyan-Palerang Regional Council 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 Queanbeyan-Palerang Regional Council.
Queanbeyan-Palerang Regional Council 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 Queanbeyan-Palerang Regional Council unless I withdraw it by contacting Queanbeyan-Palerang Regional Council or Services Australia. I can get proof of my circumstances or details from Services Australia or DVA and provide it to Queanbeyan-Palerang Regional Council so they, Queanbeyan-Palerang Regional Council 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 tick boxes: *

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

Additional Information

Queanbeyan-Palerang Regional Council will determine your eligibility to receive a rebate of up to $250 on your rates account. 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 Queanbeyan-Palerang Regional Council provides these services. Alternatively, if Queanbeyan-Palerang Regional 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 a gold card embossed with ‘TPI’ (Totally Permanently Incapacitated);
Holders of a gold card embossed with ‘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 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. For assistance from the DVA call 1800 VETERAN (1800 838 372).

Signature *

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Date

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