I authorise that any other owners of the property mentioned in section 1 of this form agree to the refund request and I authorise payment as detailed in section 2 of this form.

I hereby agree that Leeton Shire Council shall not be liable to me for any loss or damage, consequential or otherwise, suffered or incurred by the customer arising out of non-payment, delay in payment, payment of an incorrect amount, provided Council has observed the instructions in this request form.

I further agree that I am entitled to receive the refund sought and will advise any other joint account holder/applicant that I have received the refund.