Centrepay Form

Part A – Your Details

Part B – Type of request

Part C – Business Details

Safe Pets Safe Families Inc. Business Address PO Box 427, CHRISTIES BEACH SA, 5165. Business Telephone Number: 0435 805 867 Business Centrelink Reference Number 555-125-116-L

Part D - To START a new deduction

The minimum fortnightly amount is $20 per fortnight
For instance, if you have a $300 vet bill, please enter $300

Part E – To change your current deduction or target amount

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:  The information I have provided on this form to be given to the Business  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:  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.  If I cancel my Centrepay deductions, I am removing my consent for the Business to take further deduction(s) from my payments.  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)  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  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