Accommodation Supplement Application form S01

Page 1 S01 APR 2020 Write your Client number here. It can be found on your Community Services Card or SuperGold number Tell us your detailsWhat is your full name?First and middle namesSurname or family nameWhat date were you born?DayMonthYearTell us how we can contact youHOW TO ANSWER Q3:If you live in a rural area, flat/house number could include your RAPID number, fire number, emergency services TO ANSWER Q4:Mailing address can include a PO Box, rural delivery details, or C/O TO ANSWER Q5:Please only give uscontact details you d like us to do you live?

Have you received a rates rebate in the last 52 weeks? No Yes Amount $ Rating year 1 July 20 to 30 June 20 Signature The information I’ve provided in this form is true and complete. I understand what you do with my personal information and how you protect my privacy. Client’s name (print) Client’s signature Date Day Month Year 24 25 26 27

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  Supplement, Form, Applications, Rebates, Accommodation, Accommodation supplement application form

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