Pensioner Concession Application Form

APPLICATION FOR A PENSIONER CONCESSION FOR THE WHOLE OR PART OF THE YEAR COMMENCING 1 JULY.

Apply for Pensioner Concession

Rates Reference Number *

Full Name *

Address *

Email *

Phone Number *

Mobile Phone Number

1. Concession Card Type

I am a holder of either a Pensioner Concession Card, a Gold Card issued by the Department of Veterans’ Affairs (DVA) under the Veterans’ Entitlement Act 1986 (VEA) or Military Rehabilitation and Compensation Act 2004 (MRCA) and embossed with either Totally and Permanently Incapacitated (TPI); Extreme Disablement Adjustment (EDA) or War Widow/er (WW)*.

* War widow/er/wholly dependent partners must be eligible for a PCC in order to claim the pensioner concession on their rates. DVA can assist in determining your eligibility; contact DVA on 133 254 or visit www.dva.gov.au for further information on the process.

Applicant 1 Concession Card No.

Start Date

Applicant 2 Concession Card No.

Start Date

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

YesNo

If Yes, state the address of the other property

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

I am the sole owner; or

I am liable for the payment of rates and charges on this property, together with others as listed below:

Name

PCC Holder

Pension No.

Card Start Date

Relationship (e.g. spouse)

Resident of Property

% of Owner

ALL OTHER OWNERS including your spouse or de facto partner should be listed. ('Add Item' to enter additional owner details).

Declaration

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.

Applicant 1 Signature *

Draw signature|Type signatureClear

Applicant 2 Signature

Draw signature|Type signatureClear

Date (1) *

Date (2)

Applicant Confirmation

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, Applicants name 1, authorise *

I, Applicants name 2, authorise

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

I understand that:

Confirmation Centrelink/DVA will disclose personal information to 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 Council unless I withdraw it by contacting Council or the department. I can get proof of my circumstances/details from Services Australia/ Department of 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 eligible for the rebate.

I acknowledge I have read and understood this Customer Consent record. *

Applicant 1 Signature *

Draw signature|Type signatureClear

Applicant 2 Signature

Draw signature|Type signatureClear

Date *

Date

Pension Concession Card

Council requires a copy of both sides of the Pensioner Concession Card (PCC). Please upload a copy here. *

Browse

NOTE:

You can scan or take a photo of the Pension Concession Card to attach in this form.
Please ensure you provide both the front of the PCC showing the pensioner's details and the reverse which includes the pensioner's signature.
Multiple files can be attached here for applicatons containing more than one Pension Concession Card.

Privacy and Personal Information Protection Act 1998

I have read and understand the 'PRIVACY AND PERSONAL INFORMATION PROTECTION ACT 1998'. *

Save and Complete Later