Online Form - Pensioner/Senior Review Form » Shire of Donnybrook-Balingup

Assessment Number

Property Address for which the pensioner/senior rebate is claimed

Owner 1 Full Name *

Owner 1 Percentage of Ownership

Owner 1 Do you reside at the property? *

YesNo

Owner 1 What was the approx. date you occupied the property?

Owner 1 Contact Phone Number

Owner 1 Email Address

Owner 1 Concession Card Number *

Owner 1 Concession Card Type *

Owner 1 Concession Card Date of Grant

Owner 2 Full Name

Owner 2 Percentage of Ownership

Owner 2 Do you reside at the property?

YesNo

Owner 2 What was the approx. date you occupied the property?

Owner 2 What is your relationship to Owner 1?

Owner 2 Contact Phone Number

Owner 2 Email Address

Owner 2 Are you a concession card holder?

YesNo

Owner 2 Concession Card Number (if applicable)

Owner 2 Concession Card Type (if applicable)

Owner 2 Concession Card Date of Grant

Owner 3 Full Name

Please upload an image of your relevant concession cards (back and front) *

Does the property have a granny flat and/or ancillary accommodation?

YesNo

If yes, was this built before or after August 2013? And is it rented out?

Was this property purchased from the State Housing Commission (also known as Homeswest or Housing Authority)?

YesNo

If Yes, is the property shared equity, and what percentage do you own?

If Yes, are you 100% responsible for the rates?

YesNo

Are you a life tenant of this property according to the Deceased Owners Will?

YesNo

If Yes, have you previously supplied the Shire with relevant documents?

YesNo

DECLARATION:

I/We have read and understood the provision of the Act as provided with my/our previous application.
I/We have neither obtained nor applied for a rebate under the Act in respect of any other property for the charged period.
I/We do not occupy any other property.
I/We authorise the Local Government 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 Local Government to determine if I qualify for a concession, rebate or service.
I/We authorise appropriate government departments to relase to Water Corporation, Local Government and/or the Officer of State Revenue, confirmation that I/we hold a current Pensioner/Seniors Card or State Concession Card.
I/We declare that I/we am/are currently in receipt of a Pension. (applicable only to pensioners)
I/We declare that the details provided in this application are true and correct in relation to the above property.

A PENALTY OF $1,000 APPLIES FOR FALSE OR MISLEADING INFORMATION (Section 38)

Owner 1 - I confirm that I have read and understood the Review Form declaration shown above. *

YesNo