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Refund Request Form

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Applicant Details

APPLICANT DETAILS

Are you applying as an individual or Company: *

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Refund Details

REFUND DETAILS

Source of Refund: *

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You must select one of the search results

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Eg: 16-2021-300-1 and/or Development Application

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Account Details

FINANCIAL INSTITUTION ACCOUNT DETAILS TO CREDIT

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Acknowledgement

REQUEST AND AUTHORITY DIRECT CREDIT

I authorise Direct Credit to the bank account details as stated and hereby agree that Port Stephens Council shall not be liable to the customer for any loss or damage, consequential or otherwise, suffered or incurred by the customer arising out of non payment, delay in payment, payment of an incorrect amount, provided the council has observed the instructions in this request form. I further agree that I am entitled to receive the refund sought and will advise any other joint account holder/applicant that I have received the refund.

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Date:
Date:
today
Name:
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YOUR PRIVACY

Port Stephens Council is committed to protecting your privacy. We take reasonable steps to comply with relevant legislation and Council policy.

Purpose: The information you provide will enable Council to process your refund request and communicate with you about Council related matters.

Intended recipients: The information will only be used by Council, its contractors performing functions for Council, and other agencies such as government departments that have legislation allowing them to access Council records.

Supply: Legally required.

Consequence of Non Provision: If Council does not have your current details it will be unable to process a refund into your nominated financial institution account. If Council does not know your current address, correspondence might not reach you. If Council has no telephone or email address for you it might not be able to contact you about important matters relating to your property, accounts or applications.

Storage and security: This document will be placed on the relevant file and/or saved in Council’s records management system in accordance with Council policy and relevant legislation.

Access: Please contact Council on (02) 4988 0255 to enquire how you can access information.

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