Fillable Water And Sewerage Concession Application Form printable pdf download

Water and Sewerage Concession

Application form

The Water and Sewerage Concession offers a discount on water and sewerage costs up to a yearly maximum.

Please see the back of this form for eligibility criteria.

Account holder’s details

Mrs

Miss

Other

Given names

Surname

D.O.B.

Residential address

Suburb

Postcode

Home phone no

Mobile phone no

Postal address (if different from above)

Suburb

Postcode

Account holder’s concession card type

(Please )

Pensioner Concession Card (Centrelink or Veterans’ Affairs)

Health Care Card (Centrelink)

Gold Card (Veterans’ Affairs)

Account holder’s concession card number

Centrelink cards

Veterans’ Affairs cards

–

CRN

File number

Consent to check Centrelink details

•

if I withdraw my consent or do not alternatively provide proof of

my circumstances/details, I may not be eligible for the concession

I authorise:

provided by my water corporation.

•

my water corporation to use Centrelink Confirmation eServices to

Privacy statement

perform a Centrelink enquiry of my Centrelink Customer details

and concession card status in order to enable the business to

This information is collected by the Department of Health & Human

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

Services and your water corporation for the purpose of administering

•

the Australian Government Department of Human Services to

your concessions. Without this information, we are unable to provide

provide the results of that enquiry to my water corporation.

your concession.

I understand that:

You are able to request access to the personal information that

•

the Australian Government Department of Human Services will

we hold about you, and to request that it be corrected if necessary.

use information I have provided to my water corporation to confirm

1800 658 521

Please contact the Concessions Information Line on

my eligibility for the concession and will disclose to my water

with any queries about this statement.

corporation personal information including my name, address,

Declaration

payment and concession card type and status.

I declare that the information provided is true and accurate to the

•

this consent, once signed, remains valid while I am a customer

best of my knowledge, and that this property is my principal place

of my water corporation unless I withdraw it by contacting my

of residence, and is used exclusively for residential purposes.

water corporation or the Australian Government Department

of Human Services.

Note: If completing this form electronically, please print the form,

•

I can obtain proof of my circumstances/details from the Australian

sign below, and send it to your water corporation. See page 2

Government Department of Human Services and provide it to my water

of this form for the water corporations’ addresses.

corporation so that my eligibility for the concession can be determined.

Signature

Date

Water And Sewerage Concession Application Form

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