Pensioner Rate Remission - Northern Midlands Council

Were you the holder of a Concession Card on 1 July? YesNo

Card Start Date

What type of Concession Card do you have? Pensioner ConcessionAustralian Government Health CareDepartment of Veteran's Affairs Gold Card endorsed with TPI or War Widow

Concession number

Please provide a copy of your concession card (required)

Applicant details

First Name

Last Name

Date of Birth

Home Phone

Mobile number

Property details

Property Address

Postcode

State

Was this property your principal place of residence on 1 July?

YesNo

Were you partly or wholly responsible for rates on the above property?

YesNo

Are you a TasWater customer?

YesNo

Authorisation and consent

Concession declaration

In making this application:

I declare that the information I have provided is true and correctI understand that I am required to advise Council if I lose my entitlement to my Centrelink pensioner concession, Health Care or Veteran Affairs Gold endorsed TPI or war widow/widowerI understand that I am required to advise Council if I am no longer living in the property as 1 July of a financial yearI agree that by typing my name below I have signed this application

Name of Signatory

Date