Pension Concession Application Form printable pdf download

Pension Concession Application Form

IPSWICH CITY COUNCIL

Pension Concession

Application Form

Ipswich City Council is collecting personal information you supply on this form in accordance with the Local Government Act

2009. The personal information collected on this form will be used to ascertain whether you are eligible for Council and/or State

Government Subsidy. Your personal information will be accessed by persons who have been authorised to do so. Some of this

information will be given to the Department of Communities, Department of Veteran Affairs and/or Centrelink for the purpose

of determining subsidy eligibility. Your information will not be given to any other person or agency unless required by law. Your

personal information is handled in accordance with the Information Privacy Act 2009.

If you are in a retirement village, mobile home village or other similar facility, you are ONLY required to fill in section 2 and 3 and

sign the authorisation on the reverse of this application.

SECTION 1 - PROPERTY DETAILS

Assessment Number:

Property Address:

 YES

 NO

Are you the full and only owners of the property listed above?

If ‘NO’ explain the position, including details of any other non-applicant person or body holding part ownership

(including % of ownership of each party):

 YES

 NO

Is this property your principal place of residence?

Has State Government subsidy been allowed this financial year on a property:

 YES

 NO

 Within Ipswich City Council or

 Outside Ipswich City Council

If ‘YES’ give details:

SECTION 2 - APPLICANT DETAILS

FIRST APPLICANTS DETAILS

SECOND APPLICANTS DETAILS

Title:

Applicants Name:

Phone Number:

Email:

Pension Type:

Maximum Rate:

 YES

 NO

Maximum Rate:

 YES

 NO

 YES

 NO

 YES

 NO

Do you receive an overseas pension:

D.O.B

(for overseas pension recipients only)

Pension Concession Application Form

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