Pensioner Rate Remission

Were you the holder of a Concession Card on 1 July?YesNo

Card Start Date

What type of Concession Card do you have?Pensioner ConcessionAustralian Government Health CareDepartment of Veteran's Affairs Gold Card endorsed with TPI or War Widow

Concession number

Please provide a copy of your concession card (required)

Applicant details

First Name

Last Name

Date of Birth

Home Phone

Mobile number

Property details

Property Address

Postcode

Was this property your principal place of residence on 1 July?

YesNo

Were you partly or wholly responsible for rates on the above property?

YesNo

Are you a TasWater customer?

YesNo

Authorisation and consent

Concession declaration

In making this application:

I declare that the information I have provided is true and correctI understand that I am required to advise Council if I lose my entitlement to my Centrelink pensioner concession, Health Care or Veteran Affairs Gold endorsed TPI or war widow/widowerI understand that I am required to advise Council if I am no longer living in the property as 1 July of a financial yearI agree that by typing my name below I have signed this application

Name of Signatory

DECLARATION

I, authorised:

· The Northern Midlands Council (The Council) and the Department of Treasury and Finance (Treasury) to use Centrelink Confirmation eServices and perform a Centrelink/DVA enquiry of my Centrelink or Department of Veterans’ Affairs Customer details and concession card status to enable the Council and Treasury to determine if I qualify for a concession, rebate or service.

· Services Australia (the agency) to provide the results of that enquiry to the Council and Treasury.

I understand that:

· The agency will disclose personal information to the Council and Treasury including my name, address, payment type, payment type, payment and concession card type and status to confirm my eligibility for rates remission;

· This consent, once signed, remains valid while I am a customer of the Council unless I withdraw it by contacting the Council or the agency. I can get proof of my circumstances/details from the agency provide it to Council and Treasury so my eligibility for rates remission 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 rates remission provided by the Council and Treasury.

Signature

Date

Applicant details

Property details

Authorisation and consent

Contact

Address

Opening Hours