Centrepay Written Consent

Step 1 of 2

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Unique ID

This form is to be used to provide consent to Council to have payments deducted from Centrepay. Note, all details provided must match the details on your pension card.

Name(Required)

First Last

Date of birth(Required)

Phone(Required)

CRN(Required)

Property Details

Match All Match Any

Summary

Your address

Your rates assessment number

Your water account reference number

Total deduction value(Required)

Payment to deduct from(Required)

Date deductions are to commence(Required)

Fortnightly Contribution to Rates

Fortnightly Contribution to Water

The two values on this line need to add up to , which is the value in the "Total deductions value" above.

The "Next" button will not appear until the above condition is met.

Hidden

Value validation (Hidden Calculation should = $0 if contributions are correct)

I, (CRN: Date of Birth: ),
authorise the Department of Human Services to make a total deduction of each fortnight from my payment and pay this amount to Leeton Shire Council (555-054-070T) for the Rates and/or Water I owe, commencing .

I request that this deduction be split as follows:
Fortnightly payment to Rates account = $ 0.00
Fortnightly payment to Water account = $ 0.00

Further information about Centrepay can be found online at https://humanservices.gov.au/centrepay

Please provide a copy of your pension card using either the "Pension Card Upload" or "Take a photo of your pension card" option below.

Pension Card Upload

Accepted file types: jpg, gif, png, pdf, Max. file size: 128 MB.

Take a photo of your pension card

Signature

Submission Date

Hidden

Workflow Timeline

Name

This field is for validation purposes and should be left unchanged.