ACT	REVENUE OFFICE
PENSIONER RATES REBATE APPLICATION

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).
Street Address

Suburb	Section	Block	Unit	Rates Account No:

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

Please note:
The address on your card must match your residential address.

Have the applicants received a pensioner rebate of rates for any other property:  YES / NO. If yes, please provide details.

Pension No.	Date of grant

%

Applicant 1

(Given Names)
Pension Type

(Family Name)

Centrelink

Veterans’ Affairs

I have

ownership in the property.

Pension No.	Date of grant

%

Applicant 2

(Given Names)
Pension Type

(Family Name)

Centrelink

Veterans’ Affairs

I have

ownership in the property.

I/we authorise the ACT Revenue Office to use Centrelink Confirmation eServices to perform a Centrelink/DVA enquiry of my Centrelink or Department of Veterans’ Affairs Customer details and concession card status in order to enable the ACT Revenue Office to determine if I qualify for a rates rebate. The Australian Government Department of Human Services (the department) to provide the results of that enquiry to the ACT Revenue Office.

I/we understand that: the department will use information I have provided to the ACT Revenue Office to confirm my eligibility for a rebate and will disclose to the ACT Revenue Office personal infromation including my name, address, payment and concession card type and status. This consent, once signed, remains valid while I am a customer of the ACT Revenue Office unless I withdraw it by contacting the ACT Revenue Office or the department. I can obtain proof of my circumstances/details from the department and provide it to the ACT Revenue Office so that 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 provided by the ACT Revenue Office.

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	Date:	Phone:

Signature Applicant 2	Date:	Mobile:

Note: Please send your application to PO Box 252 Civic Square ACT 2608.

Giving false or misleading information is a serious offence. This form is Approved Form AF2015-37 under section 139C of the Taxation Administration Act 1999.