Looking for a Financial Assistance Application Form Templates? Download it for free!

Alcohol Ignition Interlock Program - Financial

Assistance Scheme Application

1995

Transport Operations (Road Use Management) Act

This form is to be used if you are applying for financial assistance to pay for

stating that they are a full time student, or a witnessed copy of their

the costs of fitting, maintaining and removing an approved interlock under the

university enrolment, or student card.

Alcohol Ignition Interlock Program.

Copies of supporting documents must be signed and endorsed by an approved

While you are subject to the Alcohol Ignition Interlock Program you may only

witness. The witness must sign and print their full name, position title/

drive a vehicle that has been fitted with an approved interlock and nominated to

designation and contact details (including office stamp). The copy must be

the Department of Transport and Main Roads (the department), via an interlock

endorsed with the words ‘I have sighted the original document and certify this

provider. You are responsible for all costs associated with the program.

to be a true copy of the original.’

If you are a low income earner you may be eligible for financial assistance if:

An approved witness is a person who is a:

•

you hold a valid Queensland driver licence endorsed with an ‘I’ condition

•

Doctor

(you may lodge an application prior to obtaining a driver licence with an ‘I’

•

Police Officer

condition and conditional approval may be granted pending a licence being

•

Consular or Ambassadorial Officer

obtained); and

•

Solicitor, Barrister or Judge

•

you are an Australian citizen or permanent resident; and

•

Justice of the Peace or a Commissioner for Declarations

•

the assessable income and liquid assets are below the maximum allowable

•

Notary Public or a person authorised by law to witness and sign declarations

limits which apply to your circumstances; and

•

you have not received financial assistance in the last five years.

Additional information

The lodgement of this application does not guarantee it will be approved. Your

Income and liquid assets must not exceed the limits detailed on the department’s

application cannot be considered at the time of lodgement. It must be forwarded

website, If you have a partner, their income and liquid

for consideration. You will be advised of the outcome.

assets will also be assessed. If you are a dependent child, your parent(s)/

guardian(s)’s income and liquid assets will be assessed.

You may lodge the application at your nearest departmental customer service

centre or mail to:

To help you understand this application form, listed below are the meanings of

some relevant terms —

Department of Transport and Main Roads

Interlock Processing Unit

Your liquid assets are any funds that are readily available to you, including

GPO Box 1412

money in banks, building societies, or credit unions.

Brisbane Qld 4001

A dependent child is a young person, under 22 years of age, who is:

For further information, or to obtain a copy of the Alcohol Ignition Interlock

•

wholly or substantially financially dependent on their parent(s)/guardian(s),

Program - Financial Assistance Scheme Information Sheet (S4900) visit

who have responsibility for the day-to-day care, welfare and development of

or call 13 23 80*.

the young person; and

* Higher rates apply from mobile phones or pay phones

•

receiving full time education at a school, college or university, if they are

aged 16 to 21; and

Part A: Personal details

(to be completed by the applicant)

•

not married or in a de facto relationship; and

•

not receiving a Centrelink benefit in their own right.

1. Applicant’s details

A person is considered to be your partner if you and the person are living

Family name (please PRINT)

together, or usually live together, and you are married or in a de facto

relationship (opposite or same-sex).

As part of assessing your application, the department will contact the State

Given name/s (please PRINT)

Penalties Enforcement Registry (SPER) to determine if you have any unpaid

fines registered with SPER. It is recommended you contact SPER on

1300 365 635 to ensure any fines you may have are up to date.

For approved applicants, financial assistance will be sufficient to meet the

Residential address

minimum requirements of the program in relation to the fitment, rental and

scheduled services and removal of an approved interlock. Any additional costs,

such as those incurred due to non-compliance, will not be covered.

Postcode

Supporting documents

Postal address (if same as residential, write ‘AS ABOVE’)

You will need to provide documents to support your application for financial

assistance —

•

Evidence of your identity in the form of a witnessed copy of a Category

A identity document, such as an Australian driver licence, Australian birth

Postcode

certificate, Australian citizenship certificate or naturalisation certificate, or

Australian passport. Please refer to the department’s website,

Date of birth

Daytime phone number

, for a full list of accepted Category A identity

documents.

•

Evidence of Australian citizenship or permanent residency, such as a

2. Driver licence details

witnessed copy of your Australian birth certificate, Australian passport,

Australian citizenship certificate or Department of Immigration and

Do you hold or have you ever held a Queensland driver licence?

Citizenship visa (may be the same document as provided for evidence of

identity).

•

Evidence of income:

Yes

Driver licence number (if known)

– Witnessed copies of payslips showing the last 8 weeks of income for you

and/or your partner (or your parent(s)/guardian(s) if you are a dependent

child)

– Witnessed copies of Centrelink income statements showing the last

Expiry date

8 weeks of payments for you and/or your partner (or your parent(s)/

guardian(s) if you are a dependent child)

– Details of any other income you and/or your partner (or your parent(s)/

Important: You must hold a valid Queensland driver licence endorsed

guardian(s) if you are a dependent child) receive

with an ‘I’ condition to receive financial assistance, however you may

•

Witnessed copies of statements from all accounts held by you and/or your

be granted conditional approval prior to a licence being obtained.

partner (or your parent(s)/guardian(s) if you are a dependent child), solely or

3. Fines registered with the State Penalties Enforcement

jointly, in banks, building societies, or credit unions.

Registry (SPER)

•

A witnessed copy of the Commonwealth issued Health Care Card (if

applicable).

Do you have any unpaid fines registered with SPER?

•

Evidence of dependent children such as a witnessed copy of their birth

Go to 4

certificate, or legal or other document (for foster children), for all children

whom you state are your dependants.

Yes

Contact SPER to finalise the fine or enter into a

•

Evidence that dependent children, between the ages of 16 and 21, are

satisfactory payment arrangement

enrolled in full time education, such as a letter from the secondary school

continued page 2...

Page 1 of 4 SSA Multimedia Services Form F4899 ES V01 Apr 2011

Alcohol Ignition Interlock Program - Financial Assistance Scheme Application - Queensland Department Of Transport And Main Roads

Related Articles

Related forms

Related Categories