APPLICATION FOR
A RENTAL REBATE	
Office use only

Date received:  …… / …… / ……

Received by:  ………………………….……………...….

Tenancy No:  ……………………………………...……..

Expiry date prev rebate:  …... / …... / …...

Application Number:  …………..………………...…..
  New Application
  Change of Circumstances
  Additional information for Existing Application	

Please use BLOCK LETTERS

You need to provide complete and accurate information. If you do not do so, the processing of your rental rebate details may be delayed.  Inaccurate information can also result in legal action being taken to recover rebates to which you have not been entitled.

Current Address:

………………………………………………………………………………………………………..…..
	\
Rental Payment Method: 
(e.g. Cash, Centrelink, Bank Deduction)

	……………..……...………………………

Rent Account Number:

	…….…………….……………	
Telephone Contact Numbers (Home/work/mobile):

(H)………..……....…….…..……(W)…...………….…….…………..…(M)…...……..………………………..…	

Part A – Household Particulars	

List the details of ALL persons living at your address

Full Name/s	Relationship to APPLICANT

(e.g. Domestic Partner – Son – Daughter)	Date of Birth	Type of Income

(e.g. Wages - Pension - Super)	Source of Income

(e.g. Name of Employer – Super Fund – Centrelink)	Gross Fortnightly Income

(Before tax)	Aboriginal or Torres Strait Islander descent*
	Disability or special needs *
(Use separate sheet if insufficient space)	
EXAMPLE:
John Henry Smith
	
Domestic Partner
	
12 / 03 / 62
	
Pension
	
Centrelink
	
$286.95
	
No
	
Yes
(No stairs)	

	
APPLICANT
	
.… / .… / .…

	

$

	

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$

	

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$

	

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$

	

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$

	

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$

	

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$

	

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$

	

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$
			
*  This information is required for statistical purposes and to assist Housing ACT to review existing assistance programs and develop new programs that better target the community.
If people have moved into or left the property, the Tenant(s) must provide a Statutory Declaration advising of the date the person(s) entered or departed.
If you are paying child support, please provide a Payment Assessment from Child Support Agency or other evidence. These payments are exempt from assessment for Rebate purposes.

Please Note

This application will only be assessed when all questions are fully answered and evidence of income is received.  An incorrect or incomplete application will cause delay in the assessment of your rebate.  If you are unsure how to answer any question, please contact your Housing Manager.  The complete application may be posted to Housing ACT or delivered to Housing ACT as below:
Postal Address
Housing ACT
Locked Bag 3000
BELCONNEN ACT 2616	Belconnen (Shopfront)
Applicant Services Centre
Nature Conservation House
Cnr Benjamin Way & Emu Bank
BELCONNEN ACT 2617	DROP OFF BOX ONLY
City
City Health Centre
1 Moore Street
Canberra City 	DROP OFF BOX ONLY
Woden
Phillip Health Centre
Cnr Corinna & Keltie Streets
WODEN
	DROP OFF BOX ONLY
Tuggeranong
Canberra Connect
Shop 17-21 Homeworld Shopping Centre
Reed Street, Tuggeranong 	

Part B – Other Income Sources

Has anyone in the household received any interest from savings banks, fixed deposits, credit unions, building societies
or dividends from any investments in the past year?

 Yes	 No

If YES, show details here.  The amount of money received must be shown, not the amount on deposit or invested.
Name	Annual Amount $		Name	Annual Amount $	

Current Balance of Savings $……………………………	Current Balance of Investments $…………………………

Does anyone in the household currently have an outstanding claim for workers or other form of compensation, or is
anybody intending to claim?

 Yes	 No

Note:  If YES, applicants must complete an Undertaking To Repay Rental Rebate when any payment is received.

Is anyone in the household anticipating, or has received, any lump sum payment (in the past 12 months) from third
party insurance or other source?

 Yes	 No

If YES, provide information and attach appropriate documentation………………………………………………………………………………..
………………………………………………………………………………………………………………………………………………………………

Important Information For Applicants

What is Gross Income?	
Gross Income includes all wages, salary, pensions and allowances (including overseas pensions), interest/dividends on investments, superannuation, compensation, family payments and child maintenance.

Proof Of Income

	
Each person receiving any income must provide proof of that income before a rental rebate will be assessed.  This can be any of the following:

•	Employer’s statement showing current gross and previous 26 weeks income
•	Statement showing interest/dividends (e.g. bank, credit union, dividend statement)
•	Department of Veterans’ Affairs statement
•	Centrelink statement (Centrelink clients can authorise Housing ACT to obtain the information directly by completing an authority form)
•	If you are self-employed: please refer to the Fact Sheet for Proof of Income for Self-employed Persons which is available on the Disability, Housing and Community Services website or from the Applicant Services Centre.

Declaration

I/We
•	Apply for a rebate of rent.
•	Declare that the contents of this application are true and correct in every detail, and acknowledge that the provision of false information may lead to prosecution and recovery of any rebate granted.
•	Undertake to notify Housing ACT immediately of any change to the household particulars shown so the rebate (if granted) may be varied, and acknowledge that the failure to notify Housing ACT will result in the recovery by the Commissioner for Social Housing of any overpaid rebate granted.
•	Acknowledge that:
a)	the rent rebate is for a period of six months or such other period as the Housing Commissioner may determine;
b)	at the end of the rent rebate period, I/we must submit a new Application for Rental Rebate form if I/we believe I/we have an on going entitlement to a rebate; and
c)	failure to submit this form or provide further information requested by the Housing Commissioner may result in the immediate withdrawal of the rent rebate by the Housing Commissioner.

Privacy

The personal information on this application is required under the Housing Assistance Act 2007.  
The information you provide will be treated confidentially and used to assess your entitlement to rental rebate, for statistical purposes and may be disclosed where required or authorised by or under law.  
You will have access to any information you have provided to ensure that it is still accurate, and to allow you to correct it if necessary.

Signature

…………………………………	..… / ….. / …..
		
Signature

…………………………………	..… / ….. / …..

INCOME CONFIRMATION AUTHORITY

I / We hereby authorise Centrelink to provide to Housing ACT a Centrelink Statement of Income in connection with my / our Application for Rental Rebate.  
I / We understand that the Statement will contain:
·	The type and amount of the pension or allowance payment Centrelink make to me / us.
·	The number of dependent children used to assess any family payments.
·	Details of anything being deducted from my / our payments, such as CSA payments, Centrepay deductions, Rent deductions.
·	Details of any other income I / we have told Centrelink about, such as overseas pensions, child maintenance, returns on investment, wages/salary.

These details will be used by Housing ACT to assess my / our entitlement to a Rental Rebate.

I / We consent to Centrelink providing this Statement electronically via the Income Confirmation service.  This consent is limited to providing information only in respect of this Application for Rental Rebate.

I / We understand that I / we will be able to obtain a written copy of the Statement at any time from either Housing ACT or Centrelink.

Applicant 1                                                            		Applicant 2
Full Name

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
		Full Name

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
	
Centrelink CRN

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
		Centrelink CRN

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
	
Signature

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Date  . . . . . . . / . . . . . . . / . . . . . . .		Signature

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Date  . . . . . . . / . . . . . . . / . . . . . . .	
Applicant 3                                                            		Applicant 4
Full Name

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
		Full Name

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
	
Centrelink CRN

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
		Centrelink CRN

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
	
Signature

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Date  . . . . . . . / . . . . . . . / . . . . . . .		Signature

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Date  . . . . . . . / . . . . . . . / . . . . . . .	

Statement by Employer of Employee Income

This confirms that  Mr / Mrs / Ms  …………………………………………………………………………………………

of ……………………………………………………………………………………………………………………………….

has been employed by …………………………………………………. for ………… weeks in the past 26 weeks.

During those weeks his/her gross earnings were $…………………………….

His/Her present gross weekly wage consists of:

•	Base Wage	$………………….

•	Overtime	$………………….

•	Allowances/Commission	$………………….

Total	$………………….

He/She commenced with the company on  …… / …… / ……

Statement provided by

Name of person completing this form and to whom Housing ACT may direct enquiries regarding its content

	………………………………………………………………………………………………………………………

Signature

	………………………………	…… / …… / ……
	
Position held (e.g. Manager, Treasurer)

…………………………………
	
Telephone contact No.

……………………

I ………………………………………………………………D.O.B.   ………/ ……./ ………
(Client’s Full Name)

Address …………………………………………………………………………………………

give permission to Housing ACT for the release and exchange of information in connection
with my Application for a Rental Rebate with the Company/Firm or person nominated above.

Please place company stamp or seal here

………………………………………………………………Date………/ ……./ ………
Signature