Electricity Rebate/reticulated Natural Gas Rebate (Page 4 of 4) in pdf

Department of Communities, Child Safety and Disability Services

APPLICATION FORM

Form 509 07.14

______________________________________________________________________________

Electricity Rebate and Reticulated Natural Gas Rebate

This Application Form applies only where the applicant is a consumer of electricity and reticulated natural gas

purchased from a Retail Entity.

This form must be completed by the customer and lodged with the Retail Entity for the rebate to apply. Please refer to the attached

Information Brochure before completing this application. Further assistance is available from your Retail Entity staff.

A separate application will need to be completed if your electricity retailer is different to you reticulated natural gas retailer.

_______________________________________________

Given Name

(Please Print)

Surname

___________________________________________________________________________

_______________________

Full Residential Address

(Please Print)

Telephone Number

Rebate/s being applied for (Please tick

appropriate box/boxes)

______________________________________________

My electricity account number is:

______________________________________________

My reticulated natural gas account number is:

I hold one of the following current and valid cards:

PLEASE PROVIDE CARD/FILE NUMBER

•

Veterans’ Affairs Number

PENSIONER CONCESSION CARD

Card Issued By: (Please tick

appropriate box)

Veterans’ Affairs: or

Centrelink

Department of Human Services (Centrelink)

CRN

•

DVA HEALTH CARD – FOR ALL CONDITIONS (GOLD CARD)

File Number

AND receiving either of the following benefits:

SPECIAL RATE TPI

WAR WIDOW / WIDOWER

•

QUEENSLAND SENIORS CARD

Card Number

Who I live with: (Please read the following statement carefully and tick

the box to confirm that it applies to you)

I live alone or with persons as described below:

- With my spouse/defacto and/or other persons who are wholly dependent on me

- With other people who hold a Pensioner Concession or Queensland Seniors Card

- With other people who receive a Centrelink, Family Assistance Office or Dept of Veterans’ Affairs payment, and who DO NOT

pay rent

- With other people who provide care and assistance, and who DO NOT pay rent

AND

- I DO NOT share my residence with any other persons except casual visitors.

Declaration

I advise that the above address is my principal place of residence and is the only residence within Queensland for which the rebate is

claimed by me and the above electricity/reticulated natural gas account is solely or jointly in my name

I will notify the Retail Entity immediately of any change in my circumstances, which may affect my eligibility for the rebate.

I authorise Department of Human Services (Centrelink) to confirm with <Retail Entity> the current status of my Commonwealth Benefit

and other details as they pertain to my concessional entitlement. This involves electronically matching details I have provided to the

<Retail Entity> with Department of Human Services (Centrelink) or Department of Veterans’ Affairs (DVA) records to confirm whether or

not I am currently receiving a Centrelink or DVA benefit.

I understand that this consent, once signed, is effective only for the period I am a customer of <Retail Entity>. I also understand that this

consent, which is ongoing, can be revoked any time by giving notice to <Retail Entity>.

I consent to the Retail Entity providing my details to the Department of Communities, Child Safety and Disability Services (Concession

Services and Card Services) for the purpose of determining or confirming my continue eligibility.

I declare that all the information that I have given is true and correct.

Signature of Applicant: _______________________________________________

Date: ____/____/____

Electricity Rebate/reticulated Natural Gas Rebate Page 4

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