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Declaration

Congestion Levy Form: Concession Claim Form

Fields marked with * are required

Collection statement

The information on this form is collected so that the SRO can consider your application for a concession under the Congestion Levy Act 2005. If you do not provide this information we may not able to progress your application. 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 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.

The Electronic Transactions (Victoria) Act 2000 establishes the regulatory framework for transactions to be completed electronically. This form requires you to complete an electronic signature via tick-box before lodgment. By ticking the box you indicate your approval of the contents of this electronic communication.

Date

Signature

Date (DD/MM/YYYY)

First name

Middle name(s)

Family name

Position (if applicable)

Organisation (if applicable)

Mobile number

Phone number

Email

Customer details

Congestion Levy Form: Concession Claim Form

Fields marked with * are required

Customer details

Are you an:

Individual

Entity

First name

Middle name(s)

Family name

Customer name

Name of company

ABN

ACN

SRO customer number

Mobile number

Phone number

Email

Concession claim

Congestion Levy Form: Concession Claim Form

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Concession claim

Please provide the details of the premises

Premises

Building address

What is the type of address?

Street

Lot number

Floor/Level type

Floor number

Flat/Unit type

Unit number

Lot number

Street number

Street name

Street type

Suburb/Town

State

Postcode

Detail the concession(s) claimed

Concession

Number of concession spaces

Number of days for which concession is claimed

Car park type (private/public)

Reason for concession

Document checklist

Congestion Levy Form: Concession Claim Form

Fields marked with * are required

Document checklist

Have you already filed the congestion levy annual return form?

Yes

No

Please attach the congestion levy annual return form.

File: