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Alcohol Ignition Interlock Program - Financial Assistance Scheme Application - Queensland Department Of Transport And Main Roads Page 4

Alcohol Ignition Interlock Program - Financial Assistance Scheme Application ... continued page 4 of 4

7. Bank account details

OFFICE USE ONLY

Provide details of all accounts held by you, solely or jointly, in banks,

Office stamp/declaration received:

building societies, or credit unions.

(1) Name of bank, building society or credit union

Account number

Type of account

Balance of account

Receipt number

(2) Name of bank, building society or credit union

Decision

Document/File ID

Account number

Type of account

Do you approved this application

Balance of account

Yes

Please note: you will need to provide witnessed copies of

statements for the last three months for all accounts held by

Reasons for the decision

you, solely or jointly.

If you have more than two accounts, attach a separate sheet with

details.

8. Declaration

I declare that the information I have provided in Part C of this application is

complete, true and correct in every detail.

I understand that failure to provide complete, true and correct information

may result in the application being refused, or if financial assistance is

granted on the basis of this information, the assistance will be withdrawn.

I authorise a departmental officer to make any enquiries considered

necessary for the purpose of this application.

Applicant/partner/parent/guardian’s signature

Date

It is an offence under the Criminal Code Act 1899 to dishonestly provide

information with the intent to defraud. The maximum penalty may include

ten years imprisonment.

Privacy statement: The Department of Transport and Main Roads (the

department) provides this form so that the applicant may apply for financial

assistance to meet the cost of fitting, maintaining and removing an approved

interlock. The information collected on Part C of this form is accessible by

authorised departmental persons and some of this information may be disclosed

to the Queensland Police Service. The department will not disclose your personal

details to any other third parties without your consent unless required by law.

Delegated person’s name

Position/title

Signature

Date

Page 4 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 Page 4

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