You must fill in the boxes marked *
Assessment number: *
ABN: (if applicable)
Property address *
Suburb *
Post code *
Given Name *
Surname *
Postal Address *
E-Mail Address *
Day time phone number *
Mobile Phone *
Date of Birth *
Total amount outstanding ($) *
Payment amount ($) *
Payment frequency *
Payment commencement date *
Privacy Statement

Information collected on this form is for the purpose of assessing and processing your application for an arrangement to pay with Council.
Unless stated otherwise, this information will be used solely by Council for that primary purpose or directly related purposes and will not otherwise be disclosed without your consent or as required or permitted by law.

You may apply to Council for access and/or amendment of the information.



Declaration

I have read the attached explanatory notes and am aware of all interest and charges applicable to my Rates and Charges.
I understand that in accordance with Section 172 of the Local Government Act 1989, and Council's budget resolution on overdue rates, I may be charged Penalty Interest at the prescribed rates (as per section 2 of the Penalty Interest Rates Act 1983) calculated on a daily basis, until the debt is paid in full.

This arrangement may need to be reviewed in 6 months and if an adjustment is required Council will contact you.
I Agree