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Please complete the following:

Applicant Details

Registered Ratepayer

First Name *

Last Name *

Ratepayer Address *

Telephone

Home

Mobile

Email Address

Property Details

Account Number *Your Account Number is located on the top right hand side of your rate notice.

Low Income Health Care Card

Please upload an image of your card or other supporting documentation *

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Council is collecting the information on this form so that it may consider your application. The information is only used by Council for this purpose and will not be disclosed unless required under law.

Acknowledgement

I declare that the information contained in this application is true and correct and:

Evidence provided in the form of my Low Income Health Care Card is true

*

I'd like you to contact me to discuss other forms of assistance

Signature

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Name *

Date *

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