Levy Refund Application

Step 1 of 4 - Your Details

Title *

-- Please Select --MrMrsMsMiss

First Name *

Last Name *

Company Name

Phone *

Email *

Address *

Suburb *

State *

ACTNSWNTQLDSATASVICWA

Postcode *

Do you have a different mailing address?

• Yes
• No

Postal Address

Suburb

State

ACTNSWNTQLDSATASWAVIC

Postcode

I certify that the information provided is true and correct to the best of my knowledge. *

• Yes
• No

Contact Person - Complete this if the contact person differs from the applicant

Contact Phone - Complete this if the contact person has a different phone number to the applicant

Levy Payer Letter - If you are not the original levy payer, please attach a letter from the levy payer approving this refund application

Step 2 of 4 - Building & Construction Work

Name of Principal Contractor *

Name of owner *

Building and construction work address *

Suburb *

State *

ACTNSWNTQLDSATASVICWA

Postcode *

Description of work *

Notification and Payment form number *

Completion date

Step 3 of 4 - Your Bank Details

Bank Please provide your bank details to facilitate EFT payment.

BSB number

Account number

Account name

Step 4 of 4 - Reason for Refund Request

Why are you applying for a refund? *

(Please select ONE option only)

• Work did not commence and will not commence in the future
• Cost of work is less than the original estimate by more than $20,000
• Duplicate payment
• Other

Letter confirming building/development application cancellation, OR documentation confirming no building/development application has been lodged * - If a building/development application has been lodged, a copy of the letter received from council/certifier confirming the cancellation of your application (a Form 22 is not sufficient evidence)
- If a building/development application has NOT been lodged, a Statutory Declaration confirming that no building and construction work is to be carried out at the stated address on behalf of the owners at this time.

Original Estimate ($) Enter whole numbers only

Actual Cost ($) Enter whole numbers only

Difference in cost ($) [Autofilled]

Please supply duplicate Notification and Payment form number

Documentation confirming cost of work * (The following documentation must be uploaded or the refund may be delayed. At least one of: final progress certificate, amended contract, a relevant invoice,or the certificate of completion)

Describe the reason of the claim - Please describe the reason of the claim

Relevant documentation * - The following documentation must be attached or the refund may be delayed. Please attach copies, or provide Notification and Payment Form numbers in respect of duplicate payment

Relevant documentation * - Upload any documents that will support your refund request

Submit

Date *