Life support concession and machine notification Application form Before you start filling this form, save it into your hard drive or desktop. The Life support concession assists Victorian households who hold a valid concession card with electricity costs where a member of the household uses an eligible life support machine. Non-concession households where a member of the household uses a life support machine should complete this form to notify their electricity retailer and/or water corporation that they have the machine present in their home. Please see the fourth page of this form for eligibility criteria. Account holder’s details [Please mark with an X as appropriate] Ms Mrs Miss Mr [Please fill in as appropriate] Other title (please enter preferred title) Given names Family name Residential address Suburb/town Postcode Postal address (if different to residential address) Suburb/town Postcode Home phone number Mobile phone number Electricity account details If you pay a caravan park or retirement village for your electricity please contact the Concessions Information Line on 1800 658 521 (toll free) to discuss your application. [Please fill in as appropriate] Electricity retailer Account number National metering identifier (if known)
Life support concession and machine notification Application form Before you start filling this form, save it into your hard drive or desktop. The Life support concession assists Victorian households who hold a valid concession card with electricity costs where a member of the household uses an eligible life support machine. Non-concession households where a member of the household uses a life support machine should complete this form to notify their electricity retailer and/or water corporation that they have the machine present in their home. Please see the fourth page of this form for eligibility criteria. Account holder’s details [Please mark with an X as appropriate] Ms Mrs Miss Mr [Please fill in as appropriate] Other title (please enter preferred title) Given names Family name Residential address Suburb/town Postcode Postal address (if different to residential address) Suburb/town Postcode Home phone number Mobile phone number Electricity account details If you pay a caravan park or retirement village for your electricity please contact the Concessions Information Line on 1800 658 521 (toll free) to discuss your application. [Please fill in as appropriate] Electricity retailer Account number National metering identifier (if known)