For circumstances in which rates may be rebated, and the effect of a rebate of rates, see the Rates Act 2004 Division 7.3 (Rebate of rates).

Applicant 1

			
                                                     (Given Names)                                              (Family Name)

Applicant 2

			          (Given Names)                                              (Family Name)

Property
Details

                                          Street Address   

                                          Suburb                                      Section                       Block                      Unit 
                                                                                                                                                  If in credit, do you require a refund: 
                                          Rates Account No.                                                                                YES / NO
                                          
                                          Have the applicants received a pensioner rebate of rates for any other property in the ACT:     
                                          YES / NO.  If yes, please provide details.

                                       Suburb                                      Section                       Block                      Unit 

Pension Details

                                          

                                                          Date of Grant

Applicant 1 Pension No.

Please attach a
photocopy of front and back of all applicable pension cards.

          

 Date of Grant                                           

Applicant 2 Pension No.

                                                                                                                                                                                                                                                                                                                  

Pension Type

Applicant 1

                                                                       Centrelink              Veterans’ Affairs              

Pension Type

Applicant 2

Centrelink             Veterans’ Affairs                                          			     

I have a        % interest in the property

                                                                       ACT Revenue Office
                                Pensioner Rates Rebate Application

Pension Type

(Please tick applicable box)

Ownership Details

Applicant 1

Applicant 2

                                                                        

I have a                                                 % interest in the property

                                                                                   

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 calculate the amount of pensioner rebate on rates.  The information will not be used for any other purposes.

Authorisation

                                                                                                                    

                                                                                                                             

                                                                

Declaration

I/We declare that the property mentioned in this application is my/our principal place of residence and that no concurrent rebate has been or will be granted to me/us in respect of any other property in Australia.

I/We undertake to advise the ACT Revenue Office when the property is no longer my/our principal place of residence, or if I am/we are no longer eligible pensioner(s).

                                          

Signature

                                           Applicant 1                                          Applicant 2                                          Date:

Please provide your telephone number (in case we need to contact you about your application):  (       ) 
Note: Please send your application to PO Box 252, Civic Square ACT 2608.

Contact Details

                                                                                                  

Office Use Only       

Card sighted by:                                                                             Photocopies attached:    YES / NO

Date:

Giving false or misleading information is a serious offence.
This form is Approved Form AF2004-14 under section 139C of the Taxation Administration Act 1999.