Application for Council 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.

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 *

I have read and accepted the declaration and authority

Consent

The information provided on this form is private and confidential and Queanbeyan-Palerang Regional Council must not disclose theinformation to any person or body, if it is not directly related to the purpose for which the information was collected. If you have a complaint about the use of your personal information, contact Queanbeyan-Palerang Regional Council’s Public Officer. The information contained or referred to in this application form may be corrected andupdated by you, by contacting Queanbeyan-Palerang Regional Council.

Please read the conditions and tick box below to confirm your consent to Queanbeyan-Palerang Regional Council checking your concession eligibility with Centrelink 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 Queanbeyan-Palerang Regional Council.

I authorise:

Council to use Centrelink Confirmation eServices to perform a Centrelink/DVA enquiry of myCentrelink or Department of Veterans’ Affairs customer details and concession card status to enable Queanbeyan-Palerang Regional Council to determine if I qualify for a rebate.

The Australian Government Department of Human Services (the department) to provide theresults of that enquiry to Council.

I understand that:

The department will disclose personal information to Queanbeyan-Palerang Regional Council including my name, address, payment type, 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 Queanbeyan-Palerang Regional Council unless I withdraw it by contacting Queanbeyan-Palerang Regional Council or the department.

I can get proof of my circumstances/details from the department and provide it to Queanbeyan-Palerang Regional 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 eligible for the rebate provided by Council.

I have read and accepted the above consent *

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);
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 the concession. For assistance from the DVA call 133 254.

Signature *

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Date

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