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Declaration

Congestion Levy Form: Exemption Claim Form

Fields marked with * are required

Collection statement

The information on this form is collected so that the SRO can consider your eligibility for an exemption under the Congestion Levy Act 2005. If you do not provide this information, we may not be able to determine this matter. The information collected may be used for the purposes of other SRO legislation. Where authorised by law to do so, we may also disclose this information to other government agencies including the ATO, State and Territory revenue offices, and law enforcement agencies. You can find out more about how we use and protect your information in our Privacy Policy on www.sro.vic.gov.au.

Declaration

I am the occupant of the car park(s).

I declare that I am authorised to make this declaration.

The information provided on this form and in any attached documents is complete and correct. I understand that penalties apply for giving false or misleading information or omitting information.

Signature

Date (DD/MM/YYYY)

First name

Middle name(s)

Family name

Position (if applicable)

Organisation (if applicable)

Mobile number

Phone number

Occupant details

Congestion Levy Form: Exemption Claim Form

Fields marked with * are required

Occupant details

Are you an:

Individual

Entity

First name

Middle name(s)

Family name

Name of occupant

ABN

ACN

Address

Country

Australian address

What is the type of address?

Street

PO Box

Lot number

Floor/Level type

Floor number

Flat/Unit type

Unit number

PO Box number

Post office name

Lot number

Street number

Street name

Street type

Suburb/Town

State

Postcode

International address

Street address/Postal address

Suburb/Town

State

Postcode/Zipcode

Overseas Address

Mobile number

Phone number

Declaration

Collection statement

Declaration

Occupant details

Occupant details

Australian address

International address

Exemption claim details

Exemption claim details

International address

International address

Summary

Occupant details

Australian address

International address

Exemption claim details

International address

International address