Concession Form | Forbes Shire Council

Council Account/Assessment Number:* - required

Name:* - required

Concession card type* - required

Pensioner Concession Card DVA Gold Card

Concession card number:* - required

Date of grant of concession card:

Telephone:* - required

Email:* - required

Property address:* - required

Is this your sole/principal place of living ?* - required

Yes No

When did you move into the property ?

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

Yes No

If YES, please provide the address of the other property:* - required

Are you the sole owner of the property ?* - required

Yes No

If NO, who else owns a share ? Please list the name of each co-owner and their relationship to you.* - required

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.

Signature* - required

Please type your signature

Please sign here

Date

Consent

The information provided on this form is private and confidential and your 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 your Council’s Public Officer. The information contained or referred to in this application form may be corrected and updated by you, by contacting your Council. Please read the conditions and tick box below to confirm your consent to your Council checking your concession eligibility with Centrelink or the Department of Veterans’ Affairs.

I, (enter name)* - required

Authorise:

Council to use Centrelink Confirmation eServices to perform a Centrelink/DVA enquiry of my Centrelink or Department of Veterans’ Affairs customer details and concession card status to enable Council to determine if I qualify for a rebate.
The Australian Government Department of Human Services (the department) to provide the results of that enquiry to Council.

I understand that:

The department 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 the department 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 provided by Council.

Signature* - required

Please type your signature

Please sign here

Date

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 your council provides these services. Alternatively, if your 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.