RATES PENALTY WAIVER REQUEST
Rates Instalment Number:……………………………………………………………………………………………………
Full Name / Business Name:………………………………………………………………………………………………….
Postal Address:………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………….
Daytime Phone Number:………………………………………………………………………………………………………..
Email Address:………………………………………………………………………………………………………………………..
Assessment
Number:…………………………………………………………………………………………………………………………………
Please provide an explanation for not paying your rates by the due date:
Signed……………………………………………………………………………………………………………………………………
Date………………………………………………………………………………………………………………………………………
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