Application for Financial Assistance

Complete the form to apply for financial assistance with you water account.

Water Account Assistance

Meter point number(Required)

As displayed on your water account

Water meter number(Required)

As displayed on your water account

Full name(s) of all property owners(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email(Required)

Assistance sought

Choose your desired outcome(Required)

Payment arrangement

Write off interest on charges payable

Extension of pensioner concession to avoid hardship

Medical allowance

Financial assistance due to a natural disaster

Financial assistance for low-income households or registered not-for-profit or charitable organisations who are charged a backflow device annual management charge

Backflow rebate eligibility

For your application to be processed, you must attach evidence.

Choose your eligibility(Required)

Low income household

Pensioner

Not-for-profit and charitable organisation

Supporting evidence

Please provide a copy of your Commonwealth Seniors Health Card(Required)

Max. file size: 2 GB.

Payment arrangement

Total amount(Required)

Regular repayments of(Required)

Repayment frequency(Required)

Weekly

Fortnightly

Monthly

Start date of first recurring repayment(Required)

Low income health care card

Do you or another joint owner have a low income health care card?(Required)

Yes

Copy of low income health care card(Required)

Please upload a photo of the front and back of your low income health care card.

Max. file size: 2 GB.

Pensions and benefits

Do you or another joint owner receive a pension/benefit from Centrelink or DVA?(Required)

Yes

Do you have a current Pension/Concession Card?(Required)

Yes

Name on card(Required)

Card number(Required)

Issue date(Required)

Issued by(Required)

Centrelink

DVA

Name on card

Card number

Issue date

Select one

Issued by

Centrelink

DVA

Please provide property and council details below(Required)

Details of hardship

Cause and explanation of hardship(Required)

Duration of hardship (Months/years)(Required)

Supporting documents

Please provide relevant documentation below to support your application. For any help, please contact the Water Billing Team on (02) 6623 3800.

Extension of pensioner concession

Max. file size: 2 GB.

Pensioner Concession Application form, completed by the eligible pensioner (where this has not previously been submitted to Council).

Medical allowance

Max. file size: 2 GB.

Certificate from a registered medical practitioner, stating that an individual living at the property address in the ‘Your Details’ section on page 1 of this form, is using home-based water-dependent medical equipment.

Abandonment of charges due to a concealed or undetected water leak (pensioners only)

Max. file size: 2 GB.

1. Pensioner Concession Application form, completed by the eligible pensioner (where this has not previously been submitted to Council) 2. Water Use Audit Report, completed by a licensed plumber. (Note: Council will not reimburse, or make any contribution towards the associated plumbing costs, either for the repair of the leak or for the water use audit report).

Financial assistance due to a concealed or undetected water leak (non-pensioners only)

Max. file size: 2 GB.

Water Use Audit Report, completed by a licensed plumber. (Note: Council will not reimburse, or make any contribution towards the associated plumbing costs, either for the repair of the leak or for the water use audit report).

Charitable organisations' ACNC registration ABN number

Please provide your ABN number associated with your ACNC registration.

Please upload a copy of your most recent Australian Charities and Not-for-profits Commission (ACNC) Financial Report(Required)

Max. file size: 2 GB.

Supporting documents for natural disaster financial relief

Max. file size: 2 GB.

Please upload any supporting documents relating to your application

Privacy statement and declaration

By completing and lodging this application form (and any related documents such as the Water Use Audit Report) you agree that you have provided the information requested voluntarily. The information is being collected by Rous County Council in accordance with the Privacy and Personal Information Protection Act 1998 and Council’s Privacy Management Policy. It will be used in order for Council to assess your eligibility for account assistance and for purposes related to the administration of the account assistance program, including the assessment of the effectiveness of the program. This may involve disclosing the information in this application to contractors engaged by Rous County Council. Provision of the information is voluntary, but if you do not provide the requested information, Council’s assessment of your eligibility for account assistance may be hindered.

You should note that if you are not a pensioner, a condition of applying for account assistance is that you acknowledge that you are aware that your details (including information in this application) is usually published in a report that is publicly available on our website and considered by Council at a meeting that is open to the public. For more information about this, please refer to Council’s Retail Water Customer Account Assistance Guideline, or contact a member of our Water Billing Team on (02) 6623 3800.

Rous County Council agrees to take all reasonable measures to ensure that the personal information collected by it is stored securely. You may access or correct your personal information by contacting Rous County Council by telephone on (02) 6623 3800, or by writing to: General Manager, ROUS, 20 Conway Street, LISMORE, NSW 2480. If you have a complaint about the use of your personal information, please contact Council’s Public Officer on (02) 6623 3800.

Application for Financial Assistance

Water Account Assistance

Assistance sought

Backflow rebate eligibility

Supporting evidence

Payment arrangement

Low income health care card

Pensions and benefits

Details of hardship

Supporting documents

Privacy statement and declaration

Acknowledgement of Country