Fillable NSW Family Energy Rebate Application form: Retail customers (New South Wales)

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NSW Family Energy Rebate Application form: Retail customers (New South Wales)

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NSW Family Energy
Rebate
Application form: Retail customers
NSW Department of Planning, Industry and Environment | July 2021 | 1
The NSW Family Energy Rebate helps NSW family households with dependent children cover the
costs of their energy bills.
If you receive your bill directly from your energy retailer and you meet the eligibility criteria, you can
apply for the Family Energy Rebate.
If eligible, you’ll receive the rebate from the NSW Department of Planning, Industry and Environment
of up to $180 on your energy bill.
Applications close at 11pm on Thursday 30 June 2022.
You can apply online at: www.service.nsw.gov.au/transaction/apply-family-energy-rebate-
retail-customers.
Before you start
Before filling in this application please ensure you have:
your customer reference number (CRN - issued by Services Australia (Centrelink))
your personal and contact details
your electricity retailer and account details.
Checklist
Eligibility criteria
To be eligible for this rebate you must:
be a current NSW resident
be named on the electricity account for supply of electricity at your principal place of
residence as a customer of an electricity retailer of your choice
have been assessed by the Australian Government’s Services Australia as being eligible
for the Family Tax Benefit (FTB) Part A or B for the 2020-21 financial year and have
received FTB payments in 2020-21 based on that eligibility, and
have received the FTB for the 2020-21 financial year and have had your entitlement to the
FTB payments finalised (reconciled) by Services Australia (Centrelink).
This form is for use by households that receive an
electricity bill from an electricity retailer of their choice.
NSW Family Energy
Rebate
NSW Department of Planning, Industry and Environment | July 2021 | 2
Application form: Retail customers
Important information
Applications close at 11pm on Thursday 30 June 2022.
If you have a Services Australia Concession Card or Health Care Card and meet all the
eligibility criteria for the Family Energy Rebate, your rebate credit will be approved at the lower
capped rate of $20 (for retail customers), as you also qualify for the NSW Low Income Household
Rebate. More information on the Low Income Household Rebate for retail customers is available
at: www.service.nsw.gov.au/transaction/apply-low-income-household-rebate-retail-customers.
More information
Visit the Service NSW website at: www.service.nsw.gov.au/services/concessions-rebates-and-
assistance or
Call Service NSW: 137 788
Privacy Notice
The Department of Planning, Industry and Environment (the Department), located at 4 Parramatta
Square, 12 Darcy Street, Parramatta NSW 2150, is subject to the Privacy and Personal
Information Protection Act 1998 in managing your personal information.
The Department is collecting your personal information for the purposes of processing your
application for an energy rebate (including assessing your eligibility), paying a rebate to you if you
are eligible, administering the energy rebates scheme and auditing the rebate program which may
include surveying customer experiences.
In completing this form you may provide the personal information of another person. Before you
provide this information you must seek the consent of that person to disclose their information to
the Department and for it to be used in accordance with this Privacy Notice.
The Department will disclose your CRN or DVA number to Services Australia to determine whether
you qualify for the rebate. The Department may disclose your personal information to a third party
engaged to carry out an audit of the rebate. The Department will not disclose your personal
information to anybody else unless authorised by law.
Applying for this rebate is voluntary. However, if you decide to apply, unless otherwise noted, all
personal information requested directly from you must be provided for the Department to process
your application.
You have the right to access the personal information that the Department holds about you. You
also have the right to request that the Department updates or amends this information. For further
details, email: rebates@energysaver.nsw.gov.au.
NSW Family Energy
Rebate
Application form: Retail customers
NSW Department of Planning, Industry and Environment | July 2021 | 3
Filling in this form
• Please use CAPITAL letters.
• The applicant name must match the name on your 2020-21 FTB correspondence and the
name printed on your electricity bill/invoice.
• The address included on the application must be the applicant’s principal place of residence.
Applicant details
CRN (Services Australia):
First name:
Last name:
Residential address:
Suburb:
Postcode:
Contact phone number:
Email address:
Postal address (if different from suburb above):
Suburb:
Postcode:
Electricity retailer details
Electricity retailer name:
Electricity account holder name:
Electricity account number:
National meter identifier (NMI) number:
Your NMI number is located on your electricity bill. It starts with the number 4 and is 11 digits long,
with no letters or symbols. If you cannot locate your NMI number please send a full copy of your bill
with this application and we will add the information for you.
NSW Family Energy
Rebate
Application form: Retail customers
© State of New South Wales through Department of Planning, Industry and Environment | July 2021 | 4
Consent for person to act on your behalf (optional)
Only complete this section if you would like someone to act on your behalf in relation to this
application.
I authorise , who can be
contacted by phone on to:
o speak to the Department on my behalf to assist with processing this application
o clarify any information provided in this form to assist with processing this application.
I have confirmed with the above nominated person that they agree to act on my behalf and
advised them that their information will be collected and managed in accordance with the
Privacy Notice in this form.
I understand that I can withdraw this consent at any time by contacting the Energy Rebates
Team on 02 8073 9255 or at rebates@energysaver.nsw.gov.au.
Applicant declaration and authorisation statement
I (insert name),
of residence
)
• have read and understood all information in this application form, including the Checklist
and Privacy Notice
• declare that all information provided in this application is, to the best of my knowledge, true
and correct
• understand that the Department will use Services Australia eServices to perform a Services
Australia enquiry of my Services Australia customer details and concession card status to
enable the Department to determine if I qualify for the rebate
• understand that the Department will contact my retailer to confirm that I’m a current
customer of that retailer and disclose all information in this form to my retailer.
Consent to contact (optional)
I consent for the Department to contact me about my experience in applying for the
rebate.
Power of attorney (when application signed under power of attorney)
I have attached the certified copy of the power of attorney with this application.
Applicant signature: Date:
Submitting this form
Email the completed form to: rebates@energysaver.nsw.gov.au or
Post the completed form to: NSW Family Energy Rebate, PO Box 435, Parramatta NSW 2124.
If you are posting the form, do not use staples or sticky tape on documents.
of (insert principal place
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NSW Family Energy Rebate Application form: Retail customers (New South Wales)

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Completed 22 October 2021

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