APPLICATION for PENSIONER RATE REMISSION COUNCIL and STATE SCHEMES Contact Council If You Have Any Specific Enquiries Regarding How to Complete This Form

Banana Shire Council 62 Valentine Plains Road, Biloela PO Box 412 Biloela QLD 4715 PH 07 4992 9500 • Fax 07 4992 3493 Email [email protected] • Website www.banana.qld.gov.au CCS-RA-02-002 Document Version: 21 September 2020 Page 1 of 2 APPLICATION FOR PENSIONER RATE REMISSION COUNCIL AND STATE SCHEMES Contact council if you have any specific enquiries regarding how to complete this form. Type or print clearly and select boxes where applicable. Registered Owners: Name of Applicant 1: Pensioner Concession Card (PCC) Number: Name of Applicant 2: Pensioner Concession Card (PCC) Number: APPLICANT’S DETAILS Relationship to Applicant 1: (EG. SPOUSE/DEFACTO/ BROTHER/SISTER, ETC.) Postal Address: Locality/Town: State: Postcode: Phone number: Email: Update my Postal Addresses above: Yes No Assessment Number: Street Number: PROPERTY DETAILS (CAN BE FOUND ON Street: YOUR RATE NOTICE) Locality/Town: State: Postcode: Lot Number: Registered Plan: State whether all applicant/s is/are the holder/s of either a Queensland “Pensioner Concession Card” issued by Centrelink on behalf Services Australia, or the Department of Veteran Affairs, or a ELIGIBILITY Queensland “Repatriation Health Card – For All Conditions” issued by the Department of ALLOWANCE Veterans’ affairs. Yes No Please tick one of the below to indicate whether the applicant/s is/are either The full and only owners of the property; or OWNERSHIP The life tenant/s of the property (Certified copy of the Last Will and Testament of the property owner must be provided) Is the property described above, the principal place of residence of the applicant/s? YES NO If NO, please provide a brief explanation ...................................................................................................... RESIDENTIAL .......................................................................................................................................................................................... STATUS Is the property rented: YES NO Does the applicant have a major interest in any other residential property: YES NO PENSIONER IMPORTANT: A CLEAR COPY OF CURRENT PENSIONER CONCESSION CARD/DVA CONCESSION CARD CONCESSION CARD MUST BE ATTACHED TO THIS APPLICATION Banana Shire Council 62 Valentine Plains Road, Biloela PO Box 412 Biloela QLD 4715 PH 07 4992 9500 • Fax 07 4992 3493 Email [email protected] • Website www.banana.qld.gov.au CCS-RA-02-002 Document Version: 21 September 2020 Page 2 of 2 I declare that the information that I have supplied is true and correct to the best of my knowledge and belief. I hereby declare that I have not made any other application for a pensioner remission for any other property, either in the Shire of Banana or in any other Local Government area for the rating year that I will advise Council of any future change to my circumstances as stated above. Applicant 1 I …………………………………………… authorise: Applicant 2 I …………………………………………… authorise: Banana Shire Council to use Centrelink Confirmation eServices to perform a Centrelink enquiry of my Centrelink or Department of Veterans’ Affairs customer details and concession card status in order to enable Banana Shire Council to determine if I qualify for a concession, rebate or service. Services Australia (the agency) to provide the results of that enquiry to Banana Shire Council. I understand that: PRIVACY NOTICE The agency will disclose personal information to Banana Shire Council including my name, address, payment AND DECLARATION and concession card type and status to confirm my eligibility for the pensioner remission rebate. This consent, once signed, remains valid while I am a customer of Banana Shire Council unless I withdraw it by contacting Banana Shire Council or the agency. I can get proof of my circumstances/details from the agency and provide it to Banana Shire Council so my eligibility for the pensioner rate remission rebate 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 pensioner rate remission rebate provided by Banana Shire Council. .......................................................................... signed and declared this………..day of……….…………. 20 APPLICANT 1 .......................................................................... signed and declared this………..day of……….…………. 20 APPLICANT 2 Concession Card type CLink DVA New Applicant/s Yes No Applicant/s Signed Consent Yes No Date of effect ……./……../……… OFFICE USE ONLY Change of Address actioned (if applicable) Yes No (PENSIONER VERIFICATION CHECKLIST) Authorised Officer: ……………………………………… Date: ……./……../……… Entered in Practical: Yes No Pro-Rata Date: ……………………………………. Services Aust Reference No.: ………………………… Application checked by: ……………………………….. Date: ……./……../……….

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