Water and Sewerage Concession Application Form

Water and Sewerage Concession Application Form
HP Records
LMW Name No
LMW Prop/TCR ID
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Postal
Date of Birth

DayMonthYear
Date
Home Phone
Mobile Phone
Email
example@example.com
Postal Address (If differs from Residential)
Account holders concession card type and Number

Pensioner Concession Card (Centrelink or Vet Affairs)Health Care Card (Centrelink)Gold Card (Vet Affairs
CRN
File Number
Date of Grant

DayMonthYear
Date
Consent to check Centrelink details:

I authorise:

*Lower Murray Water (LMW) to use Centrelink confirmation eServices to perform a Centrelink/Department of Veterans Affairs (DVA) enquiry of my Centrelink/DVA customer details and concession card status in order to enable the business to determine if I qualify for a concession.

*The Australian Government Department of Human Services (the department) to provide the enquiry results to LMW.

I understand that:

*The Department will use information I have provided to LMW to confirm my eligibility for the concession and will disclose to LMW personal information including my name, address, concession card type and status.

*This consent, once signed, remains valid while I am a customer of LMW unless I withdraw it by contacting LMW or the Department.

*I can obtain proof of my circumstances/ details from the Department and provide it to LMW so that my eligibility for the concession 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 concession provided by LMW.

Privacy Statement: This information is collected by the DHHS & LMW for the purpose of administering your concessions. Without this information, we are unable to provide your concession. You are able to request access to the personal information that we hold about you and to request that it be corrected if necessary. Contact the Concessions Information Line on 1800 658 521 with any queries about this statement.
Consent Declaration: I declare that the information provided is true and accurate to the best of my knowledge, and that this property is my principal place of residence, and is used exclusively for residential purposes.
Signature

Clear
Date

DayMonthYear
Date
LMW Officer for Signed consent
Telephone Consent:
Method Used to confirm customer identity (eg. DOB/ Known to Officer etc)
Consent Script read and agreed to Y/N?
Taken in MDA/SH/KER/in FIELD?
Consent Date

DayMonthYear
Date
Consent Time

:HourMinutesAM/PM Option
LMW Officer for verbal consent:

Concession Details:

	Qtr No Curr/Retro	Concession Value	Fln Maint
-
-
-
-
-
Total Concession

CCeS Verification:
CCes Y/N:
CCes Checked (lnits):
CCeS Checked Date

DayMonthYear
Date
CCeS Rejection reason/ cust advised?
LMW Notes/ Retro Reason:
Future Conc only Y/N?
PAM Maintenance:
Customer Maint Journal No:
SIGNED consent recorded?
Verbal consent recorded?
Property Charges Journal No:
PAM Maint Processed (lnits):
PAM Maint Processing Date

DayMonthYear
Date
Amended Notice reqd? Y/N
Sent? Y/N
Should be Empty: