ACT REVENUE OFFICE
RATES DEFERRAL (PENSIONER) APPLICATION

                                   Please send application to PO Box 252 CIVIC SQUARE  ACT  2608

For the circumstances in which rates may be deferred, and the effect of a deferral of rates, see the Rates Act 2004, Division 7.2 (Deferral of rates).

PLEASE USE BLOCK LETTERS

  Please provide the full name and address of all owners.

Please indicate the type of pension and your pension number

Centrelink						Pension Number

Department of Veterans’ Affairs (DVA)		Pension Number

Pension Details

Property Details

SUBURB

SECTION

BLOCK

UNIT

Is the property your principal place of residence?	Yes    	No    	  

Full Name:

Address:

Contact Phone No.				        (H)				      (W)

Full Name:

Address:

Contact Phone No.				        (H)				      (W)

I/We 
(Full name of applicant/owners)
hereby declare that:

•	I/We wish to make an application for a deferment of rates.
•	To the best of my/our knowledge and belief, the information provided in this application is true and correct.

I/We authorise the Commonwealth Service Delivery Agency (Centrelink) or the Department of Veterans’ Affairs to disclose to the ACT Revenue Office the following information from my/our records: name, date of eligibility for concession, and if relevant, date of loss of eligibility for concession.  This information will be used by the 
ACT Revenue Office to confirm the information I/we have provided on this application and to confirm my/our eligibility for a deferment of rates.  The information will not be used for any other purposes.

Please note that:	1.  All applicant/owners must sign the application.
2.	Giving false or misleading information is a serious offence.

This form is Approved Form AF2004-13 under section 139C of the Taxation Administration Act 1999.

Declaration

Signature						Date:		/	/

Please indicate which charges you would like deferred

Rates Arrears					Current Year’s Rates

Interest						Future Year’s Rates ##

**Costs and expenses reasonably 		## If you elect to defer future year’s rates, all
incurred by the Commissioner in		future rates (less your rebate entitlement) will be
attempting to recover the rates		automatically deferred.  You can stop the
	deferment of future rates at any time by
** Only applicable if the ACT Revenue	requesting, in writing, that the deferment of 
Office has initiated legal action to		future rates stop.
recover outstanding rates charges.

Deferment