STATE GOVERNMENT PENSIONERRATE SUBSIDY APPLICATION APPLICANT DETAILS

Full Name of Applicant/s Customer Reference NumberOr File Number

Start Date/Date of Grant

Property ID

Residential address Telephone

Home:

Mobile:

Email

Please note: A copy of both sides of the applicant/s current pension card must be provided with this application.

PROPERTY DETAILS This is my principal place of residence and I reside at this property

Yes No (If no, please give details)

I am the full and only owner of this property Yes No (If no, please give relationship to all owners)

Eg: Husband/Wife Mother/Son

I/We authorise Scenic Rim Regional Council (Council) to use Centrelink Confirmation eServices to perform a Centrelink/Department of Veterans' Affairs enquiry of my Centrelink or Department of Veterans' Affairs customer details and concession card status to enable the business to determine if I qualify for a rate concession. I/We, the above applicants, authorise The Australian Government Services Australia (the department) to provide the results of that enquiry to Council. I/We understand that the department will disclose personal information to Council including my name address concession card type and status to confirm my eligibility for a rate concession. This consent once signed, remains valid while I/We am a customer of Council unless I/We withdraw it by contacting Council or the department. I/We can get proof of my circumstances/details from the department and provide it to Council so my eligibility for rate concession can be determined. I/We may revoke this consent record at any time by giving Council written notice. I/We understand that if I/We withdraw my consent or do not alternatively provide proof of my circumstances/details I may not be eligible for the rate concession from Council.

IMPORTANT NOTICE – Privacy Statement Scenic Rim Regional Council is collecting your personal information on this form for the purpose of assessing your application for pensioner remission some of this information may be given to Centrelink or other Commonwealth Departments or agencies for the purpose of determining eligibility. Your information will not be given to any other person or agency unless you have given permission or are required by law. Your personal information is handled in accordance with the Information Privacy Act 2009.

Applicant/s Signature: Date:

To submit your form to Council

Scenic Rim Regional Council, PO Box 25, BEAUDESERT QLD 4285Beaudesert Customer Service Centre 82 Brisbane Street, Beaudesert Boonah Customer Service Centre 70 High Street, Boonah Tamborine Library & Customer Service Cnr Main St & Yuulong Rd, Tamborine Mountain

(07) 5540 5111 (07) 5540 5103 mail@scenicrim.qld.gov.au

A new application will need to be completed and copies of your new eligible pensioner card will need to be provided if you move address including if you sell your principal place of residence and move to another property within the region, or change from a Centrelink customer to a Veterans' Affairs customer.