Refund Application Form

Required fields are marked with an asterisk (*).

Part A: Applicant Details

Surname *

Given Name(s) *

Business Name

Mailing Address *

Contact Number *

Email *

Part B: Payment Information

Date of payment *

What is the refund for? * e.g. hire bonds, paid rates for wrong property, overpayment for animal registration, please explain

Method of payment *

Online
Phone
BPAY
In person at Council Office
Australia Post
Other - please specify

Other

Rates property number As shown on Rates Notice (this field must be completed if applying for a rates refund)

Part C: Details for Direct Deposit of Refund (Cheque or Savings Accounts Only)

Banking Institution Name *

Account Name *

Account Number *

BSB *

Part D: Original Payment Verification Check

To verify the applicant and method of payment, one of the below documents is required. * Please note, your application will not be processed if one of these documents is not provided with this application.

Copy of Receipt
Copy of Credit Card Statement or Bank Statement (remove credit card details)

Part E: Privacy Statement

Your personal information is being collected by Alexandrina Council for the purpose of assessing whether you are entitled to a refund. Your information will be assessed by Council Staff and will be stored in Council’s Database.

Application Declaration

I declare that the information provided on this form is true and correct. I agree with the terms and conditions associated with the refund process.

Applicant Full Name *

Applicant Signature * Type name

Date *