Select Your Concession Card:

Your House Number:

Email Address:

Card Valid From:

Card Valid Until (if applicable):

Card Number (including any letters):

Upload Image - Front of Card:

Upload Image - Back of Card:

Your Given Name:

Your Surname:

Your Full Residential Address:

Your Telephone (Land or Mobile):

Who You Live With:
Please read the following statement carefully and tick ✓ the box to confirm that this applies to your living arrangements.

Yes, I can confirm I either live alone or only with persons as described below:

• With my spouse/defacto and/or other persons who are wholly dependent on me.
• With other people who hold a concession card or Queensland Seniors Card
• With other people who receive a Centrelink, Family Assistance or Dept of Veterans’ Affairs payment, and who DO NOT pay rent
• With other people who provide care and assistance, and who DO NOT pay rent AND
• I DO NOT share my residence with any other persons except casual visitors.

• Momentum Energy Pty Ltd (Momentum Energy) to use Centrelink Confirmation eServices to perform a Centrelink/DVA enquiry of my Centrelink or Department of Veterans’ Affairs customer details and concession card status to enable the business to determine if I qualify for a concession, rebate or service.
• Services Australia (the agency) to provide the results of that enquiry to Momentum Energy. I understand that:
  • The agency will disclose personal information to Momentum Energy including my name, address, payment type, payment status and concession card type and status to confirm my eligibility for the electricity rebate.
  • This consent, once signed, remains valid while I am a customer of Momentum Energy unless I withdraw it by contacting the Momentum Energy or the agency. I can get proof of my circumstances/details from the agency and provide it to Momentum Energy so my eligibility for the electricity rebate can be determined.
  • If I withdraw my consent or do not alternatively provide proof of my circumstances/details, I may not be eligible for the electricity rebate provided by Momentum Energy.

• I will notify Prospecta Utilities or Momentum Energy immediately of any change in my circumstances which may affect my eligibility for the electricity rebate.

• Momentum Energy to disclose my personal information to the Department of Home Affairs (DHA) or Department of Child Safety, Seniors and Disability Services (DCSSDS) and their service delivery agent (Card and Concession Services, Smart Service Queensland) to confirm my eligibility for the electricity rebate.
• DHA or DCSSDS to provide the results of that enquiry to Momentum Energy

• DHA or DCSSDS will use information I have provided to Momentum Energy to confirm my eligibility for the electricity rebate and will disclose to Momentum Energy personal information including my name, address and card number and status.
• this consent, once signed, remains valid while I am a customer of Momentum Energy unless I withdraw it by contacting Momentum Energy
• I can obtain proof of my circumstances/details from DHA or DCSSDS and provide it to Momentum Energy so that my eligibility for the electricity rebate can be determined
• if I withdraw my consent or do not alternatively provide proof of my circumstances/details, I may not be eligible for the electricity rebate

I declare that all the information that I have given is true and correct. I have read and understand the above terms.