Registration Concession Application

1 Registration Concession Application - Pensioners, Seniors and Prescribed Service Persons- Special Interest VehiclesTransport Operations (Road Use Management) Act 1995 transport Operations (Marine Safety) Act 1994 Section B - Special Interest Vehicle ConcessionApplicant s name (please print)Make and type of vehicle/ship ( Ford sedan)Section A - Pensioners, Seniors and Prescribed Service PersonsSection B - Special Interest Vehicle (SIV)Please only complete the section relevant to the type of Concession you are eligible for. See Concession Conditions Department of transport and Main Roads (TMR) Customer Reference Number (CRN). The CRN is your Queensland (Qld) Driver Licence number, Adult Proof of Age or Photo Identification Card number or your reference number issued by Registration number (if allocated)Ship Registration number (if allocated)*Pensioner Concession Card number*Note: Pensioner and Seniors Card must be Qld : applications made by post or email must include a copy of the front and back of the Concession card or supporting letter.

2 *Seniors Card numberPrescribed Service Persons numberName of spouse3. Do you or your spouse receive a Registration Concession on any other vehicle/ship?Residential addressPostcodeSection A - Pensioners, Seniors and Prescribed Service Persons ConcessionPlease enter one of the following:1. Applicant detailsI have a vehicle that is one of the following: (tick a box)Ye sYe sNew CTP classIn the SIV Guide. For a copy of the guide go this form for pensioners, seniors and prescribed service persons (see section A Concession Conditions)I hereby provide the following documents:NoNoAt least 30 years old (includes tractors)Historic bus at least 25 years oldHistoric ambulance/fire-fighting equipment (no age limit)Street Rod/Hot Rod vehicle with an original body and frame built before 1949, or a replica that has been modified for safe road use and is fitted with a modification plate (code LH9 or LH10).

3 Please provide the plate number in Question SIV number plate will be issued unless you wish to attach personalised/customised green on white provide personalised/customised green on white plate number and complete the Remove and/or Attach Personalised/Customised Number Plate/s Application (form F2964).continued page Page 1 of 2 LTSR Forms Area F3937 CFD V01 Apr 2021 Date of issue/ /Ye sNoOnly one vehicle/ship Concession can be applied per spousal couple. What is the Registration number of that vehicle/ship?Go to 7 Evidence of current club membership with an incorporated vehicle club/association (if applicable)Certificate of Incorporation as a historical society with a recognised interest in vehicle heritage (if applicable)Certification from a dating officer/club official of the vehicle s authenticity and year of manufacture (if applicable).

4 See section B overleaf for requirements and conditions of vehicle Are green on white, personalised, historic, or SIV plates attached to the vehicle?6. Compulsory Third Party (CTP) insurance class Do you wish to change your CTP class?2. Vehicle/Qld Regulated Ship detailsGo to 4 Email addressMobile/Telephone number4. Do you authorise TMR to remove this Concession if applicable?Ye sThe Concession on that vehicle/ship may be Application cannot be to 7 Note: Class 5 CTP insurance covers motor vehicles (including motorbikes) for use only as vintage, veteran, historic or street rods. For details on CTP vehicle classes, visit CertificationIt is an offence to give false or misleading information under the transport Operations (Road Use Management) Act. Maximum penalty may exceed $ agree to inform TMR of any change which may affect my/our eligibility to retain the Concession within 14 days.

5 I/we certify that information and statements provided in this Application are true and correct. I/we agree to use the vehicle in accordance with the conditions of the Concession as outlined (please tick one box):ororRegistration Concession Application - Pensioners/Seniors/Prescribed Service Persons; - Special Interest Vehicles .. continued page 2 of 2 Section B - Special Interest Vehicle ConcessionI/we understand that if a vehicle on Concession is operated outside the conditions of the Concession , a penalty infringement notice may be issued or I/we may be prosecuted by a court or the Concession may be withdrawn. I/we consent to TMR verifying the evidence of identity information provided with the relevant issuing authority or other operator signature/sDate/ / Applicants must be residents of Qld and holders of: Pensioner Concession Card (Qld issued) Seniors Card (Qld issued) A current (signed) DVA/Veteran Gold Card embossed with TPI (Totally or Permanently Incapacitated) or EDA (Extreme Disability Adjustment) or A current non embossed (signed) DVA/Veteran Gold Card or DVA/Veteran White Card accompanied with a DVA letter stating the applicant: is at least 70% incapacitated under the Veterans Entitlement Act 1986 or has been assessed as having at least 50 impairment points under the Military Rehabilitation and Compensation Act 2004.

6 Lodge applications at a customer service centre or, if you live in a rural area, a Queensland Government Agency Program office, Magistrates Court or a local police station that provides vehicle Registration services. Alternatively by mail: PO Box 2211 BRISBANE QLD 4001 or email: Note: applications must include a copy of the front and back of the Concession card or supporting letter, refer ConditionsSection A - Pensioner, Seniors and Prescribed Service Persons ConcessionConcession Card sighted:Physical cardDigital walletConcession codeSIV requirements met:Office/Agency use only The Concession only applies to motor vehicles not over tonnes GVM, motorbikes, motorised caravans (no GVM limit) with a private purpose of use and ships. The Concession document must be in the same name as the registered operator of the vehicle or ship and must be mainly for the applicant s own private use.

7 An eligible person may only receive one Concession for their vehicle and one for their ship at any one time. Only one Concession per spousal couple will apply. If vehicle/ship is registered in joint names the following applies: For a spousal couple, where both are eligible for a Concession , either person may submit an Application . If only one person is eligible, the Application must be made by that person. For other relationships, both persons must be eligible for a Concession and each must submit an Application . Sole parent Concession card holders can only have concessional Registration if they are the sole registered operator. Pension card holders need to provide proof of their eligibility for concessional Registration to move the Concession to another vehicle.

8 All other Concession types will only need to complete this Application to withdraw and apply the Concession to their new next 2 of 2 LTSR Forms Area F3937 CFD V01 Apr 2021 The SIV Guide sets out the requirements for registering vehicles under the scheme and the conditions/restrictions under which the scheme operates. The SIV Guide is located at Conditions/RestrictionsRegistered operators of SIV vehicles or anyone driving the vehicle should be familiar with the vehicle conditions of use/restrictions outlined within the SIV guide. If the vehicle is used outside of these conditions/restrictions, you may be fined or risk having the Concession Scheme Registration RequirementsSee SIV Guide for street rods/hot rods requirements. Historic vehicle club membership Evidence of current membership with an incorporated vehicle club/association must be provided at Application and needs to: be on club letterhead include details of your vehicle (make, model, year and chassis number) be signed by a club official.

9 Historic Dating and Vehicle Certificate (if applicable) A dating certificate is only required at Application if the date of manufacture cannot be verified. If required, a dating officer/club official will need to certify on club letterhead/official club documentation that the vehicle is authentic and was manufactured at least 30 years Statement: TMR is collecting the information on this form for the purpose of maintaining the TMR vehicle Registration register as required under the transport Operations (Road Use Management) Act. TMR or its agents/contractors may use your information in its communications with you and where relevant, may give some of the information to vehicle insurers, statutory entities, insolvency entities, lawyers, persons involved in vehicle incidents/accidents, vehicle manufacturers, third parties who are involved in or intend to commence legal proceedings, tolling entities, law enforcement agencies and interstate registering authorities.

10 Your personal information will not be disclosed to any third party without your consent, unless authorised or required to do so by law. Vehicle/Ship concessionapplied from:Refund amountRefund reference numberIf the refund is to be issued by EFTPOS/Credit:I confirm that all requirements have been met to issue an electronic IDDate/ // /$Verifying Operator s usernameVerifying Operator s signatur