Application for rental rebate

For public housing renters

You may be eligible for a Victorian Government subsidy, known as a rental rebate, which can reduce your weekly
payment amount for public housing to 25 per cent of household income.

Section A- General information

Daniel cooke
A1 Your tenancy details
4/24 Ballantyne at Thornbury
Renter name(s)

0435185103
Rental address

Phone number
Account number

Income
A2 Please tell us the reason you are completing this application (for example, regular rent review,
details
someone joining or leaving the household, change in income type or amount for any household member)

Centerlin
k new
start
allowance
$685 per
Important informationfortnight
You may have to attach specific supporting documents to this form for each member of the household who is not
participating in Services Australia’s Income Confirmation Service.
Each renter must sign the declaration at the end of this form.
If you need an interpreter or help to fill out this form, please contact your local office. Lodging this form
When you have filled in the form and attached the documents we need, send or deliver your application to your
local Department of Families, Fairness and Housing office.
OFFICE USE ONLY
/ / Yes / No
Date received Account Number / Address Received by (name) Application complete
Section B- Household income and asset information

B1 Please list all persons currently living in the home, as well as those who have recently
moved in or out.
Gross (before tax) incomes of all occupants from any source must be listed, including pensions, family
allowance payments, child maintenance, compensation, savings, investments, assets, real estate, and property,
etc

Household Member details Gross weekly income Savings/

investments/ assets
Full name Date Male/ Relationship Date Income Weekly Asset Amount
of Female to renter moved in type amount Type
Birth or out of (before
the tax)
property
$

$
$

$
$
Other than when a household member moves out or buys or sells real estate, we need documents confirming
each type of income received and asset held by each household member that has not consented to Services
Australia’s Confirmation eServices.
A person who wilfully provides false information to the Department of Human Services in order to obtain a
rebated rent may be liable to penalties under section 40 of the Housing Act 1983 (VIC)
Declaration and acknowledgement

I/we

Daniel
___________________ (all renters’ names) have attached the required documentation to support my/our
cookd
application for a rental rebate.
I/we declare that the information contained in this application is true and correct.
SIGNATURE(S:

Daniel Cooke 28/03/23

______________________________________________________________________________________

DATE: _______________________
Section C- Services Australia eServices

Services Australia Confirmation eServices (CCeS) is an online service that allows us to obtain information
directly from Services Australia, to confirm your eligibility for housing services.
You and your household members can provide consent by signing this form and selecting the services you wish
to use:
income confirmation (for example information about your income and assets)
contact and address verification (for example your address details)

Consent
I/we authorise Services Australia to provide the Director of Housing, being a body corporate established
under the Housing Act 1983 (Vic) of 50 Lonsdale Street, Melbourne, or their representative, with statements of
information to assist in the assessment of one or more of the following:
entitlement for rental rebate
ongoing eligibility for social housing
application for bond assistance
application for social housing
I/we understand that the information provided by Services Australia to the Director or his/her representative,
may contain but is not limited to the information listed under ‘Information we can get directly from Services
Australia’.
I/we understand that this authority, once signed, is effective for the period I am/we are a client of the Director
of Housing or their representative
I/we understand that this authority, which is ongoing, can be revoked at any time by giving written notice to the
Director of Housing or their representative
I/we understand that this authority is voluntary and can be withdrawn at any time by giving written notice to the
Director of Housing or their representative

Household member details Authority (mark which

authority is being
provided)
Full name Date of Services Income Address Signature Date
birth Australia Confirmation verification
Reference
Number (CRN)

3 Application for rental rebate