Water and Sewerage Life Support Rebate Application Form

Water/sewerage accounts only

I hereby register as a customer dependant upon life support equipment.

This form is used for obtaining a rebate when you depend on life support equipment, which requires a fresh supply of water.

To complete this form you will need:

a printer (connected to your computer—this form needs to be printed and submitted to us)
a current letter of authority signed by your medical practitioner or an authorised officer of the ACT Department of Health, specifying the type of equipment and the amount of time in use.

Please note on approval of your application the rebate will be applied to your next bill.

Please print this form, complete your details, sign and attach the appropriate authorisation:

mail to:
Customer Services
ActewAGL
GPO Box 366
Canberra ACT 2601

fax:
6248 3244

scan and email to:
[email protected]

Call 6248 3111 (opt 2) for assistance.

* Required fields

Applicant details

First name *

Surname *

Telephone contact number *

Application

I hereby apply for a *

Water usage life support

Account details

Water account number

Name account is in

Equipment used

I, or a member of my household, is dependent on equipment requiring water supply.

Equipment

Equipment in use from

(dd/mm/yyyy)

Authorisation

* I will notify ActewAGL immediately should a change in principal place of residence from that shown above occur, or should a change in circumstance affect eligibility for any rebate.
* I authorise ActewAGL to make any enquiries necessary to confirm eligibility for the rebate.
* I enclose a letter from a medical practitioner/authorised officer stating my need for life support equipment.
I enclose a letter from the Renal Clinic stating usage details of my Dialysis Machine.

Disclaimer

Icon Water cannot guarantee that water supplies will never be interrupted. Every endeavour is made to notify you in advance, but unplanned interruptions to supplies may also occur without warning.

If uninterrupted water supplies are essential, it is your responsibility, as the applicant, to make alternative arrangements for emergency situations.

Signature of applicant

Date