Centrepay Form

Centrepay Form

Centrepay Form

Part A – Your Details

Your last name is your pets last name

Part B – Type of request

Part C – Business Details

Safe Pets Safe Families Inc. Business Address PO Box 427, CHRISTIES BEACH SA, 5165. Business Centrelink Reference Number 555-125-116-L

Part D - To START a new deduction

This is the amount your caseworker would of informed you of

Part E – To change your current deduction

If you are setting up a new deduction, go straight to Part F

Part F – Authorisation – Read, sign and date the statement

I give permission for: SPSF The information I have provided on this form to be given to the Business SPSF The Business that I have nominated on this form to provide my correct account of billing number to the Department of Human Services if required I understand that: SPSF It is my choice to have this amount deducted from my Centrelink payment(s) and I can change my Centrepay deduction(s) at any time. SPSF If I cancel my Centrepay deductions, I am removing my consent for the Business to take further deduction(s) from my payments. SPSF If I stop using the Business but do not stop my Centrepay deduction(s), the Business may instruct the Department of Human Services to stop the deduction(s) SPSF If I have a current Centrepay deduction and I lodge a new claim, then the existing deduction(s) will not carry over to the new claim SPSF If I have current Centrepay deduction(s) and I transfer to another Centrelink payment that allows Centrepay, I should confirm that my deduction(s) have been transferred
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