Pensioner Concession Application

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.

Applicant Details

Council Account/ Assessment Number:*

Applicant Name*

First Name Last Name

Concession Card Type*

(eg Pensioner Concession Card, DVA Gold Card)

Concession Card Number*

Date of Grant of Concession Card*

Phone Number*

Email Address*

Property Details

Property Address*

Street Address Suburb State Post Code

Is this your sole / principal place of living?*

Yes
No

When did you move into the property?

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

Yes
No

(if Yes, please provide the address of the other property)

Street Address Suburb State Post Code

Are you the sole owner of the property?*

Yes
No

If no, who else owns a share?

Spouse
Other

Further Details (if applicable):

(If more than one other co- owner please list the name of each co-owner and their relationship to you.)

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

CONSENT

The information provided on this form is private and confidential and Council must not disclose the information 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 Council’s Public Officer. The information contained or referred to in 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 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 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:

Services Australia 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 agency. 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.

Please Acknowledge*

I have read and accepted the above consent

Date Signed:*

Additional Information:

Your 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 they are provided by your local Council.

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.