Fillable F4899 CFD Alcohol Ignition Interlock Program - Financial Assistance Scheme Application

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F4899 CFD Alcohol Ignition Interlock Program - Financial Assistance Scheme Application

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Country of origin: AUSTRALIA
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Alcohol Ignition Interlock Program - Financial
Assistance Scheme Application
Transport Operations (Road Use Management) Act 1995
This form is to be used if you are required to participate in the Alcohol Ignition Interlock Program and you are applying for nancial
assistance to pay for the costs of tting, maintaining and removing an interlock device.
You may be eligible to apply if you meet all the following criteria:
• you hold (or intend to hold) a valid Queensland driver licence endorsed with an ‘I’ condition
• you are an Australian citizen or permanent resident
• you have not received Alcohol Ignition Interlock Program nancial assistance in the last ve years
• your income and the money in your bank account/s are below the maximum allowable limits (go to www.tmr.qld.gov.au/interlocks).
This includes your partner or, if you are a dependent child, your parents/legal guardian
• you have made arrangements with State Penalties Enforcement Registry (SPER) to pay any outstanding nes.
Additional information
Applications can be lodged up to six weeks prior to your disqualication end date or at any time during your interlock period.
You may lodge the application by emailing to AIIP.IPU@tmr.qld.gov.au or mailing to:
Department of Transport and Main Roads
Interlock Processing Unit
GPO Box 1412
BRISBANE QLD 4001
Lodging this application does not guarantee approval. You will be notied in writing of the outcome of your application.
For further information visit www.tmr.qld.gov.au/interlocks or call 13 23 80*.
* Higher rates apply from mobile phones or pay phones
continued page 2...
Page 1 of 4 LTSR Forms Area Form F4899 CFD V01 Jun 2020
1. Applicant’s details
Family name (please print)
Given name/s (please print)
Email address
Residential address
Postal address (if same as residential, write ‘as above’)
Postcode
Postcode
Date of birth Contact phone number/s
/ /
Yes No
Would you like to receive emailed notications and reminders?
Yes
No
You must contact SPER on 1300 365 635 and make arrangements to pay. If you don’t, your application may be refused.
If your application is approved and your licence is suspended by SPER, your assistance may be cancelled and you
won’t be able to reapply for ve years. Go to 4.
Go to 4
2. Queensland driver licence number (if known)
3. Do you have unpaid nes with SPER?
Print Form
Reset Form
Alcohol Ignition Interlock Program - Financial Assistance Scheme Application ... continued page 2 of 4
4. What type of applicant are you?
Single (Attach all documents ticked from Column A)
Partnered (Attach all documents ticked from Column B).
A person is considered to be your partner if you and the person are living together, or usually live
together, and you are married or in a de facto relationship (of any gender).
Dependent child under 22 (Attach all documents ticked from Column C)
A dependent child is a person under 22 years of age who:
• completely or almost completely relies on their parent(s)/guardian(s) to look after their welfare
and pay for things like food, shelter and clothing
• attends full time education at a school, college or university, if they are aged 16 to 21
• is not married or in a de facto relationship
• is not receiving a Centrelink benet in their own right.
continued page 3...
Page 2 of 4 LTSR Forms Area Form F4899 ES V01 Jun 2020
You must provide copies of all the documents shown below that apply to you. If you don’t, your application
may be refused.
Document
Applicant type
A
Single
B
Partnered
C
Dependent child under 22 years
Applicant Applicant Partner Applicant Parents/Guardians
Evidence of Australian citizenship or
permanent residency:
• Must be witnessed by an approved person
• Australian Birth Certicate/Passport/
Citizenship certicate/VISA.
Note: A driver licence is not evidence.
An ‘approved person’ includes a Justice of the
Peace, Doctor, Police Ofcer, Solicitor/Barrister/
Judge, Consular Ofcer, Notary Public.
ü ü ü
Health care card (if applicable):
• Photocopy front and back
ü ü ü
Pay slips (if employed):
• Eight weeks’ pay slips
◊ issued immediately prior to application.
ü ü ü ü ü
Centrelink Income Statements (if receiving
Centrelink benets):
• Eight weeks’ Centrelink Income Statements:
◊ issued immediately prior to application
◊ must display name.
ü ü ü ü ü
Bank Statements:
• Eight weeks of bank statements for all
accounts:
◊ issued in the eight weeks immediately
prior to application
◊ must display account holder name/s and
account balance.
ü ü ü ü ü
Other income:
• Copy of evidence (most recent tax return and
nancial statements) of any other income, for
example:
◊ child support
◊ shares
◊ rental properties
◊ business (e.g. farming/self-employed)
◊ income stream product (super, marked-
lined pension, annuity)
◊ compensation, insurance or damages
payment
ü ü ü ü ü
Alcohol Ignition Interlock Program - Financial Assistance Scheme Application ... continued page 3 of 4
It is an offence under the Criminal Code Act 1899 to dishonestly provide information with the intent to defraud. The maximum
penalty may include 10 years’ imprisonment.
It is an offence under the Criminal Code Act to dishonestly provide information with the intent to defraud. The maximum penalty
may include 10 years’ imprisonment.
Privacy statement: TMR provides this form so that the applicant may apply for nancial assistance to meet the cost of tting, maintaining and removing an approved
interlock. The information collected on this form is accessible by authorised TMR persons and some of this information may be disclosed to the Queensland Police
Service. TMR will not disclose personal details to any other third parties without consent unless required by law.
Privacy statement: TMR provides this form so that the applicant may apply for nancial assistance to meet the cost of tting, maintaining and removing an approved
interlock. The information collected on this form is accessible by authorised TMR persons and some of this information may be disclosed to the Queensland Police
Service. TMR will not disclose personal details to any other third parties without consent unless required by law.
Applicant’s signature
Parents’/Guardian’s signature
Parents’/Guardian’s signature
Date
Date
Date
/ /
/ /
/ /
5. Applicant’s declaration
6. Parents’/Guardian’s declaration
(if applicable)
I declare that the information I have provided in this application is complete, true and correct in every detail.
I understand that failure to provide complete, true and correct information may result in the application being refused, or if
nancial assistance is granted on the basis of this information, the assistance will be withdrawn.
I authorise a TMR ofcer to make any enquiries considered necessary for the purpose of this application, including contacting
SPER.
I declare that the information I have provided in this application is complete, true and correct in every detail.
I understand that failure to provide complete, true and correct information may result in the application being refused, or if
nancial assistance is granted on the basis of this information, the assistance will be withdrawn.
I authorise a TMR ofcer to make any enquiries considered necessary for the purpose of this application, including contacting
SPER.
continued page 4...
Page 3 of 4 LTSR Forms Area Form F4899 ES V01 Jun 2020
Document
Applicant type
A
Single
B
Partnered
C
Dependent child under 22 years
Applicant Applicant Partner Applicant Parents/Guardians
Birth certicate for all dependent children (if
applicable):
• Must be witnessed by an approved person for
all dependents
• A dependent child is under 22 years of age
• Another ofcial document can be provided for
fostered/adopted children.
An ‘approved person’ includes a Justice of the
Peace, Doctor, Police Ofcer, Solicitor/Barrister/
Judge, Consular Ofcer, Notary Public.
ü ü ü
Evidence that dependent children between
16 and 21 years are full-time students:
• Copy of:
◊ student ID or
◊ enrolment conrmation from education
institution.
ü ü ü
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Alcohol Ignition Interlock Program - Financial Assistance Scheme Application ... continued page 4 of 4
Page 4 of 4 LTSR Forms Area Form F4899 CFD V01 Jun 2020
It is an offence under the Criminal Code Act to dishonestly provide information with the intent to defraud. The maximum penalty
may include 10 years’ imprisonment.
Privacy statement: TMR provides this form so that the applicant may apply for nancial assistance to meet the cost of tting, maintaining and removing an approved
interlock. The information collected on this form is accessible by authorised TMR persons and some of this information may be disclosed to the Queensland Police
Service. TMR will not disclose personal details to any other third parties without consent unless required by law.
Partner’s signature
Ofce use only
Ofce stamp/application received:
Date
/ /
7. Partner’s declaration (if applicable)
I declare that the information I have provided in this application is complete, true and correct in every detail.
I understand that failure to provide complete, true and correct information may result in the application being refused, or if
nancial assistance is granted on the basis of this information, the assistance will be withdrawn.
I authorise a TMR ofcer to make any enquiries considered necessary for the purpose of this application, including contacting
SPER.
Decision
No Yes
Would you approve this application?
Reasons for the decision
Delegated person’s name
Position/title
Signature
Date
/ /
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signature
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F4899 CFD Alcohol Ignition Interlock Program - Financial Assistance Scheme Application

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Completed 2 July 2020

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