Pension Concession Application Form (Page 2 of 2) in pdf

SECTION 3 - CARD DETAILS

Card No:

Card Type:

Issue Date:

Card Type:

Issue Date:

*Applicant/s must be receiving maximum rate of pension to receive council remission.

** A copy of the card must also be sighted.

CUSTOMER CONSENT

I authorise:

•

The Ipswich City Council to use Centrelink Confirmation eServices to perform a Centrelink/DVA 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 concession, rebate or service.

•

The Australian Government Department of Human Services (the department) to provide the results of that enquiry to

Ipswich City Council.

I understand that:

•

The department will disclose personal information to Ipswich City Council including my name/address/payment type/

payment status and concession card type and status to confirm my eligibility for, relevant concession/rebate/service.

•

(for overseas pensioner recipients), the department will disclose personal information to Ipswich City Council including my

name/address/ concession card status/payment type/payment status/one off payment/income/assets/deductions/shared

care arrangements/partner status/youth allowance independent rate to confirm my eligibility for relevant concession/

rebate/service.

•

This consent, once signed, remains valid while I am a customer of Ipswich City Council unless I withdraw it by contacting

Ipswich City Council or the department.

•

I can get proof of my circumstances/details from the department and provide it to Ipswich City Council so my eligibility for

relevant concession/rebate/service 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

concession/rebate/service provided by Ipswich City Council.

FIRST APPLICANTS DETAILS

SECOND APPLICANTS DETAILS

Signature:

Date:

OFFICE USE ONLY

STATE CODE:

Application Taken By:

Date:

COUNCIL CODE:

I confirm that the card has been sighted physically or electronically

and the below are correct on this form. Tick when correct.

Council Remission:

Enviroplan Remission:

Name:

Adjustment Processed:

 YES

 NO

Address

Objective Doc No:

Pension Type:

Application Processed By:

Issue Date:

Date:

Card Number:

The Ipswich City Council (Council, we, our, us) collects and manages personal information in the course of performing its activities, functions and duties. We respect the

privacy of the personal information held by us. The way in which the Council manages personal information is governed by the Information Privacy Act 2009 (Qld) (the Act).

We are collecting your information to enable you to change your address details. Generally, we will not disclose your personal information outside of Council unless we are

required to do so by law, or unless you have given us your consent to such disclosure. By returing your application to Council, we will consider that you have given us your

consent to manage your personal information in the manner described in Council’s Privacy Statement, Personal Information Digest and this collective notice.

PO Box 191, Ipswich Q 4305 | T (07) 3810 6666 | F (07) 3810 6731 | E council@ipswich.qld.gov.au | W Ipswich.qld.gov.au