Pension Rebate Application

Customer number *

First name *

Last name *

Number and street address *

Locality *

State *

Postcode *

Phone number *

Email *

I hereby apply for a pensioner rebate for *

Water Availability and Sewerage Availability Charges

Water Availability Charges only

The above mentioned property is *

Owned and occupied by myself and is my principal place of residence

Owned jointly by my spouse and myself and is my/our principal place of residence

Occupied by myself and I am liable for charges under the terms of a life tenancy (proof of life tenancy under a will must be provided)

The property is owned and occupied in the manner indicated above and *

I/We do not receive a pension rebate on another property for water or sewer

I am the holder of a current Pensioner Concession Card of the type indicated

Centrelink

Veterans' Affairs

T.P.I

War Widow

Centrelink/DVA Customer Reference Number (CRN) *

Date of grant (card start date) *

Authorisation and consent

By submitting this form I authorise Essential Water 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 to enable the business to determine if I qualify for a concession, rebate or service, and for the Australian Government Department of Human Services (the department) to provide the results of that enquiry to Essential Water.

I understand that

I understand that:

the department will disclose personal information to Essential Water including my name, address, payment type, payment status and concession card type and/or status to confirm my eligibility for a pensioner rebate.

this consent, once signed, remains valid while I am a customer of Essential Water unless I withdraw it by contacting Essential Water or the department.

I can get proof of my circumstances/details from the department and provide it to Essential Water so my eligibility for a pensioner 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 pensioner rebate provided by Essential Water.