Pensioner Concession Application Form - Online

Assessment Number

Name

Concession Card Type (eg. Pensioner Concession Card, DVA Gold Card)

Concession Card Number

Card Start Date

Phone Number

Email

Property Address

Postal Address

Is this property your sole / principal place of living?

When did you move into this property?

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

if Yes, please provide the address of the other property

Are you the sole owner of the property?

If you selected Other in the previous question, please provide details

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 Camden 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 Camden Council’s Public Officer. The information contained or referred to in this application form may be corrected and updated by you, by contacting Camden Council.

Please read the conditions and tick box below to confirm your consent to Camden 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 Camden Council.

I

Full name of individual making the above declaration:

authorise:

Camden 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 Camden Council.

I understand that:

Confirmation eServices will disclose personal information to Camden Council including my name/address/ payment type/payment status and concession card type status to confirm my eligibility for a rebate.

This consent, once signed, remains valid while I am a customer of Camden Council unless I withdraw it by contacting them or the department. I can get proof of my circumstances/details from Services Australia/ Department of Veterans Affairs and provide it to Camden Council so my eligibility for the 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 have read and accepted the above consent

Additional Information

Council will determine your eligibility to receive a rebate of up to $250.00 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.