The information contained in this application form and any information requested for the purpose of assessing eligibility for a pensioner concession is required under the Local Government Act 1993 and the Local Government (General) Regulation 2005.

By submitting this form, you declare that the information provided is true and correct and that you are the person making this application. If you make a false statement in an application, you may be guilty of an offence and fined up to $2,220.

Consent:

The information provided on this form is private and confidential and Council must not disclose the information to any person or body, if it is not directly related to the purpose for which the information was collected.

If you have a complaint about the use of your personal information, contact Council’s Public Officer. The information contained or referred to in this application form may be corrected and updated by you, by contacting Council.

I consent:

• Council to use Services Australia Confirmation eServices to perform a Centrellink/DVA enquiry of your Centrelink or DVA customer details and concession card status to enable Council to determine if I qualify for a rebate.

• Services Australia will provide the results of that enquiry to Council.

I understand that:

• Confirmation eServices will disclose personal information to Council including my name, address, payment type, payment status and concession card type and status to confirm my eligibility for a rebate.

• This consent, once signed, remains valid while I am a customer of Council unless I withdraw it by contacting Council or the department.

• I can get proof of my circumstances/details from Services Australia/Department of Veterans Affairs and provide it to Council so my eligibility for a 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 rebate.