Application For Housing Assistance Form (Page 18 of 19) in pdf

Income Confirmation Scheme Consent Authority

If you or anyone on this application wish to participate in the Centrelink Income Confirmation Scheme please complete

the consent form below.

This consent will be used for the sole purpose of authorising Centrelink to provide information to the Department of

Family and Community Services (FACS) to assess your eligibility for concessions or services provided by FACS.

If you do not want Centrelink to provide your information electronically to FACS, you will need to obtain the information

required from Centrelink yourself and provide it to FACS.

Please read and sign the consent and the declaration below:

I authorise the Department of Family and Community Services (FACS) to use Centrelink Confirmation eServices to

perform a Centrelink enquiry of my Centrelink Customer details and concession card status in order for FACS to

determine if I qualify for a concession, rebate or service.

I authorise the Australian Government Department of Human Services to provide the results of that enquiry to

FACS.

I understand that the Department of Human Services will use information I have provided to FACS to confirm my

eligibility for concessions, rebates or services and will disclose to FACS my personal information including my

name, address, concession card status, payment type, payment status, income, assets, one-off payments,

deductions and shared care arrangements.

I understand that this consent, once signed, remains valid while I am a customer of FACS unless I withdraw it by

contacting FACS or the Department of Human Services.

I understand that I can obtain proof of my circumstances/details from the Department of Human Services and

provide it to FACS so that my eligibility for concessions, rebates or services can be determined.

I understand that if I withdraw my consent or do not alternatively provide proof of my circumstances/details, I may

not be eligible for the concessions, rebates or services provided by FACS.

Centrelink

Customer

Family name

Given name(s)

Date of birth

Signature

Date

Reference

Number

DD/MM/YYYY

More information about Centrelink Confirmation eServices is available from Centrelink or on Centrelink’s website at

Interpreting Services

If you need help with interpreting or translation because English is not your first language, phone the All Graduates

Interpreting and Translating Service on 1300 652 488. They will phone the social housing provider and interpret for you

for free.

DH3001 04/15

Page 16 of 16

Application For Housing Assistance Form Page 18