Form 4899 ES "Financial Assistance Scheme Application - Alcohol Ignition Interlock Program" - Queensland, Australia

Form 4899 ES is a Queensland Department of Transport and Main Roads form also known as the "Financial Assistance Scheme Application - Alcohol Ignition Interlock Program". The latest edition of the form was released in April 1, 2011 and is available for digital filing.

Download an up-to-date Form 4899 ES in PDF-format down below or look it up on the Queensland Department of Transport and Main Roads Forms website.

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Download Form 4899 ES "Financial Assistance Scheme Application - Alcohol Ignition Interlock Program" - Queensland, Australia

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Alcohol Ignition Interlock Program - Financial
Assistance Scheme Application
1995
Transport Operations (Road Use Management) Act
This form is to be used if you are applying for financial assistance to pay for
stating that they are a full time student, or a witnessed copy of their
the costs of fitting, maintaining and removing an approved interlock under the
university enrolment, or student card.
Alcohol Ignition Interlock Program.
Copies of supporting documents must be signed and endorsed by an approved
While you are subject to the Alcohol Ignition Interlock Program you may only
witness. The witness must sign and print their full name, position title/
drive a vehicle that has been fitted with an approved interlock and nominated to
designation and contact details (including office stamp). The copy must be
the Department of Transport and Main Roads (the department), via an interlock
endorsed with the words ‘I have sighted the original document and certify this
provider. You are responsible for all costs associated with the program.
to be a true copy of the original.’
If you are a low income earner you may be eligible for financial assistance if:
An approved witness is a person who is a:
•
you hold a valid Queensland driver licence endorsed with an ‘I’ condition
•
Doctor
(you may lodge an application prior to obtaining a driver licence with an ‘I’
•
Police Officer
condition and conditional approval may be granted pending a licence being
•
Consular or Ambassadorial Officer
obtained); and
•
Solicitor, Barrister or Judge
•
you are an Australian citizen or permanent resident; and
•
Justice of the Peace or a Commissioner for Declarations
•
the assessable income and liquid assets are below the maximum allowable
•
Notary Public or a person authorised by law to witness and sign declarations
limits which apply to your circumstances; and
•
you have not received financial assistance in the last five years.
Additional information
The lodgement of this application does not guarantee it will be approved. Your
Income and liquid assets must not exceed the limits detailed on the department’s
application cannot be considered at the time of lodgement. It must be forwarded
website, www.tmr.qld.gov.au. If you have a partner, their income and liquid
for consideration. You will be advised of the outcome.
assets will also be assessed. If you are a dependent child, your parent(s)/
guardian(s)’s income and liquid assets will be assessed.
You may lodge the application at your nearest departmental customer service
centre or mail to:
To help you understand this application form, listed below are the meanings of
some relevant terms —
Department of Transport and Main Roads
Interlock Processing Unit
Your liquid assets are any funds that are readily available to you, including
GPO Box 1412
money in banks, building societies, or credit unions.
Brisbane Qld 4001
A dependent child is a young person, under 22 years of age, who is:
For further information, or to obtain a copy of the Alcohol Ignition Interlock
•
wholly or substantially financially dependent on their parent(s)/guardian(s),
Program - Financial Assistance Scheme Information Sheet (S4900) visit
who have responsibility for the day-to-day care, welfare and development of
www.tmr.qld.gov.au or call 13 23 80*.
the young person; and
* Higher rates apply from mobile phones or pay phones
•
receiving full time education at a school, college or university, if they are
aged 16 to 21; and
Part A: Personal details
(to be completed by the applicant)
•
not married or in a de facto relationship; and
•
not receiving a Centrelink benefit in their own right.
1. Applicant’s details
A person is considered to be your partner if you and the person are living
Family name (please PRINT)
together, or usually live together, and you are married or in a de facto
relationship (opposite or same-sex).
As part of assessing your application, the department will contact the State
Given name/s (please PRINT)
Penalties Enforcement Registry (SPER) to determine if you have any unpaid
fines registered with SPER. It is recommended you contact SPER on
1300 365 635 to ensure any fines you may have are up to date.
For approved applicants, financial assistance will be sufficient to meet the
Residential address
minimum requirements of the program in relation to the fitment, rental and
scheduled services and removal of an approved interlock. Any additional costs,
such as those incurred due to non-compliance, will not be covered.
Postcode
Supporting documents
Postal address (if same as residential, write ‘AS ABOVE’)
You will need to provide documents to support your application for financial
assistance —
•
Evidence of your identity in the form of a witnessed copy of a Category
A identity document, such as an Australian driver licence, Australian birth
Postcode
certificate, Australian citizenship certificate or naturalisation certificate, or
Australian passport. Please refer to the department’s website,
Date of birth
Daytime phone number
www.tmr.qld.gov.au, for a full list of accepted Category A identity
/
/
documents.
•
Evidence of Australian citizenship or permanent residency, such as a
2. Driver licence details
witnessed copy of your Australian birth certificate, Australian passport,
Australian citizenship certificate or Department of Immigration and
Do you hold or have you ever held a Queensland driver licence?
Citizenship visa (may be the same document as provided for evidence of
identity).
No
•
Evidence of income:
Yes
Driver licence number (if known)
– Witnessed copies of payslips showing the last 8 weeks of income for you
and/or your partner (or your parent(s)/guardian(s) if you are a dependent
child)
– Witnessed copies of Centrelink income statements showing the last
Expiry date
8 weeks of payments for you and/or your partner (or your parent(s)/
/
/
guardian(s) if you are a dependent child)
– Details of any other income you and/or your partner (or your parent(s)/
Important: You must hold a valid Queensland driver licence endorsed
guardian(s) if you are a dependent child) receive
with an ‘I’ condition to receive financial assistance, however you may
•
Witnessed copies of statements from all accounts held by you and/or your
be granted conditional approval prior to a licence being obtained.
partner (or your parent(s)/guardian(s) if you are a dependent child), solely or
3. Fines registered with the State Penalties Enforcement
jointly, in banks, building societies, or credit unions.
Registry (SPER)
•
A witnessed copy of the Commonwealth issued Health Care Card (if
applicable).
Do you have any unpaid fines registered with SPER?
•
Evidence of dependent children such as a witnessed copy of their birth
No
Go to 4
certificate, or legal or other document (for foster children), for all children
whom you state are your dependants.
Yes
Contact SPER to finalise the fine or enter into a
•
Evidence that dependent children, between the ages of 16 and 21, are
satisfactory payment arrangement
enrolled in full time education, such as a letter from the secondary school
continued page 2...
Page 1 of 4 SSA Multimedia Services Form F4899 ES V01 Apr 2011
Alcohol Ignition Interlock Program - Financial
Assistance Scheme Application
1995
Transport Operations (Road Use Management) Act
This form is to be used if you are applying for financial assistance to pay for
stating that they are a full time student, or a witnessed copy of their
the costs of fitting, maintaining and removing an approved interlock under the
university enrolment, or student card.
Alcohol Ignition Interlock Program.
Copies of supporting documents must be signed and endorsed by an approved
While you are subject to the Alcohol Ignition Interlock Program you may only
witness. The witness must sign and print their full name, position title/
drive a vehicle that has been fitted with an approved interlock and nominated to
designation and contact details (including office stamp). The copy must be
the Department of Transport and Main Roads (the department), via an interlock
endorsed with the words ‘I have sighted the original document and certify this
provider. You are responsible for all costs associated with the program.
to be a true copy of the original.’
If you are a low income earner you may be eligible for financial assistance if:
An approved witness is a person who is a:
•
you hold a valid Queensland driver licence endorsed with an ‘I’ condition
•
Doctor
(you may lodge an application prior to obtaining a driver licence with an ‘I’
•
Police Officer
condition and conditional approval may be granted pending a licence being
•
Consular or Ambassadorial Officer
obtained); and
•
Solicitor, Barrister or Judge
•
you are an Australian citizen or permanent resident; and
•
Justice of the Peace or a Commissioner for Declarations
•
the assessable income and liquid assets are below the maximum allowable
•
Notary Public or a person authorised by law to witness and sign declarations
limits which apply to your circumstances; and
•
you have not received financial assistance in the last five years.
Additional information
The lodgement of this application does not guarantee it will be approved. Your
Income and liquid assets must not exceed the limits detailed on the department’s
application cannot be considered at the time of lodgement. It must be forwarded
website, www.tmr.qld.gov.au. If you have a partner, their income and liquid
for consideration. You will be advised of the outcome.
assets will also be assessed. If you are a dependent child, your parent(s)/
guardian(s)’s income and liquid assets will be assessed.
You may lodge the application at your nearest departmental customer service
centre or mail to:
To help you understand this application form, listed below are the meanings of
some relevant terms —
Department of Transport and Main Roads
Interlock Processing Unit
Your liquid assets are any funds that are readily available to you, including
GPO Box 1412
money in banks, building societies, or credit unions.
Brisbane Qld 4001
A dependent child is a young person, under 22 years of age, who is:
For further information, or to obtain a copy of the Alcohol Ignition Interlock
•
wholly or substantially financially dependent on their parent(s)/guardian(s),
Program - Financial Assistance Scheme Information Sheet (S4900) visit
who have responsibility for the day-to-day care, welfare and development of
www.tmr.qld.gov.au or call 13 23 80*.
the young person; and
* Higher rates apply from mobile phones or pay phones
•
receiving full time education at a school, college or university, if they are
aged 16 to 21; and
Part A: Personal details
(to be completed by the applicant)
•
not married or in a de facto relationship; and
•
not receiving a Centrelink benefit in their own right.
1. Applicant’s details
A person is considered to be your partner if you and the person are living
Family name (please PRINT)
together, or usually live together, and you are married or in a de facto
relationship (opposite or same-sex).
As part of assessing your application, the department will contact the State
Given name/s (please PRINT)
Penalties Enforcement Registry (SPER) to determine if you have any unpaid
fines registered with SPER. It is recommended you contact SPER on
1300 365 635 to ensure any fines you may have are up to date.
For approved applicants, financial assistance will be sufficient to meet the
Residential address
minimum requirements of the program in relation to the fitment, rental and
scheduled services and removal of an approved interlock. Any additional costs,
such as those incurred due to non-compliance, will not be covered.
Postcode
Supporting documents
Postal address (if same as residential, write ‘AS ABOVE’)
You will need to provide documents to support your application for financial
assistance —
•
Evidence of your identity in the form of a witnessed copy of a Category
A identity document, such as an Australian driver licence, Australian birth
Postcode
certificate, Australian citizenship certificate or naturalisation certificate, or
Australian passport. Please refer to the department’s website,
Date of birth
Daytime phone number
www.tmr.qld.gov.au, for a full list of accepted Category A identity
/
/
documents.
•
Evidence of Australian citizenship or permanent residency, such as a
2. Driver licence details
witnessed copy of your Australian birth certificate, Australian passport,
Australian citizenship certificate or Department of Immigration and
Do you hold or have you ever held a Queensland driver licence?
Citizenship visa (may be the same document as provided for evidence of
identity).
No
•
Evidence of income:
Yes
Driver licence number (if known)
– Witnessed copies of payslips showing the last 8 weeks of income for you
and/or your partner (or your parent(s)/guardian(s) if you are a dependent
child)
– Witnessed copies of Centrelink income statements showing the last
Expiry date
8 weeks of payments for you and/or your partner (or your parent(s)/
/
/
guardian(s) if you are a dependent child)
– Details of any other income you and/or your partner (or your parent(s)/
Important: You must hold a valid Queensland driver licence endorsed
guardian(s) if you are a dependent child) receive
with an ‘I’ condition to receive financial assistance, however you may
•
Witnessed copies of statements from all accounts held by you and/or your
be granted conditional approval prior to a licence being obtained.
partner (or your parent(s)/guardian(s) if you are a dependent child), solely or
3. Fines registered with the State Penalties Enforcement
jointly, in banks, building societies, or credit unions.
Registry (SPER)
•
A witnessed copy of the Commonwealth issued Health Care Card (if
applicable).
Do you have any unpaid fines registered with SPER?
•
Evidence of dependent children such as a witnessed copy of their birth
No
Go to 4
certificate, or legal or other document (for foster children), for all children
whom you state are your dependants.
Yes
Contact SPER to finalise the fine or enter into a
•
Evidence that dependent children, between the ages of 16 and 21, are
satisfactory payment arrangement
enrolled in full time education, such as a letter from the secondary school
continued page 2...
Page 1 of 4 SSA Multimedia Services Form F4899 ES V01 Apr 2011
Alcohol Ignition Interlock Program - Financial Assistance Scheme Application ... continued page 2 of 4
Part B: Parent/Guardian’s details
4. Australian residency details
(to be completed by the
applicant’s parent(s)/guardian(s) only if the applicant is a
Are you an Australian citizen or permanent resident?
dependent child)
No
You are not eligible for financial assistance
1. Parent/guardian’s details
Yes
Go to 5
Family name (please PRINT)
Please note: You will need to provide a witnessed copy of evidence
of your Australian citizenship or permanent residency.
5. Health Care Card details
Given name/s (please PRINT)
Do you hold a valid Commonwealth issued Health Care Card?
No
Go to 6
Residential address
Yes
Card number
Postcode
Expiry date
Postal address (if same as residential, write ‘AS ABOVE’)
/
/
Please note: You will need to provide a witnessed copy of the health
care card (front and back).
Postcode
6. Relationship details
Date of birth
Daytime phone number
What is your current relationship status?
/
/
Married
(You and your partner both need to complete Part C of this form)
2. Relationship details
In a de facto relationship (opposite or same-sex)
(You and your
partner both need to complete Part C of this form)
What is your current relationship status?
Single or separated
(You, or your parent(s)/guardian(s) if you are a
Married
(You and your partner both need to complete Part C of this form)
dependent child, need to complete Part C of this form)
In a de facto relationship (opposite or same-sex)
(You and
7. Dependent child details
your partner both need to complete Part C of this form)
Do you have dependent children?
Single or separated
(You need to complete Part C of this form)
No
Go to 8
3. Dependent child details
Yes
How many dependent children are in your care?
Do you have dependent children, other than the applicant?
No
Go to 4
Please note: You will need to provide a witnessed copy of birth
Yes
How many dependent children are in your care, including
certificates, or legal or other documents for all children who you
the applicant?
state are your dependants.
8. Financial dependency details
Please note: You will need to provide a witnessed copy of birth
Are you a dependent child?
certificates, or legal or other documents for all children who you
No
Go to 9
state are your dependents, including the applicant.
Yes
Your parent/guardian will need to complete Part B and
4. Declaration
Part C of this form
(If your parent/guardian has a partner they
I declare that the information I have provided in Part B of this application is
will also need to complete Part C of this form).
complete, true and correct in every detail.
9. Declaration
I understand that failure to provide complete, true and correct information
I declare that the information I have provided in Part A of this application is
may result in the application being refused, or if financial assistance is
complete, true and correct in every detail.
granted on the basis of this information, the assistance will be withdrawn.
I understand that failure to provide complete, true and correct information
I authorise a departmental officer to make any enquiries considered
may result in my application being refused, or if financial assistance is
necessary for the purpose of this application.
granted on the basis of this information, the assistance will be withdrawn.
Parent/guardian’s signature
I authorise a departmental officer to make any enquiries considered
necessary for the purpose of this application, including contacting the State
Penalties Enforcement Registry.
Date
Applicant’s signature
/
/
It is an offence under the Criminal Code Act 1899 to dishonestly provide
Date
information with the intent to defraud. The maximum penalty may include
ten years imprisonment.
/
/
It is an offence under the Criminal Code Act 1899 to dishonestly provide
Privacy statement: The Department of Transport and Main Roads (the
information with the intent to defraud. The maximum penalty may include
department) provides this form so that the applicant may apply for financial
ten years imprisonment.
assistance to meet the cost of fitting, maintaining and removing an approved
interlock. The information collected on Part B of this form is accessible by
authorised departmental persons and some of this information may be disclosed to
Privacy statement: The Department of Transport and Main Roads (the
the Queensland Police Service. The department will not disclose personal details to
department) provides this form so that you may apply for financial assistance
any other third parties without consent unless required by law.
to meet the cost of fitting, maintaining and removing an approved interlock.
The information collected on Part A of this form is accessible by authorised
departmental persons and some of this information may be disclosed to the
Queensland Police Service, State Penalties Enforcement Registry and the approved
interlock provider with whom you enter into an agreement. The department will not
disclose your personal details to any other third parties without your consent unless
required by law.
continued page 3...
Page 2 of 4 SSA Multimedia Services Form F4899 ES V01 Apr 2011
Alcohol Ignition Interlock Program - Financial Assistance Scheme Application ... continued page 3 of 4
Part C: Financial declaration
(to be completed by the
(b) Please provide details of the income earned from your
involvement in the business
applicant and their partner if applicable, or the applicant’s parent/
guardian and their partner if applicable)
$
per annum
A separate financial declaration is required for each applicable
Please note: you will need to provide a witnessed copy of your
person (applicant/applicant’s partner/applicant’s parent or
most recent taxation return and business financial statements.
guardian/ applicant’s parent or guardian’s partner – please print
4. Income stream product details
additional pages as required.
An income stream product is a regular series of payments which may be
Name of person completing the financial declaration
made for a lifetime or a fixed period including, allocated pension/
annuity, superannuation pension, market-lined pension/annuity.
(a) Are you receiving income from an income stream product?
I am the:
No
Go to 5
applicant
Yes
Income stream product type
applicant’s partner
applicant’s parent/guardian (on whom the applicant is dependent)
(b) Please provide details of the income earned
applicant’s parent/guardian’s partner
$
per annum
Please note: you will need to provide a witnessed copy of your
1. Employment income details
most recent taxation return and financial statements for this
income source.
(a) Are you currently employed?
If you received income from more than one income stream product
(Do not include self-employment – refer to section 3)
attach a separate sheet with details.
No
Go to 2
5. Compensation, insurance or damages payment details
Yes
Employer’s name
Income from compensation, insurance or damages includes workers’
compensation, sporting injury compensation, public liability compensation,
medical negligence compensation, personal accident and sickness
Address
insurance, income protection insurance, third party damages as a result of
a vehicle accident, damages paid to victims of crime or as a result of
criminal injuries.
(a) Are you receiving payments from compensation, insurance or
Postcode
damages claims?
Phone number
No
Go to 6
Yes
Payment type
If you received income from more than one employer attach a
separate sheet with details.
(b) Please provide details of the income earned (after tax) from your
(b) Please provide details of the payment received
employment in the past eight weeks
$
per annum
$
Week 1
$
Week 5
Please note: you will need to provide a witnessed copy of your
$
Week 2
$
Week 6
most recent taxation return and financial statements for this
payment.
$
Week 3
$
Week 7
If you received payments from more than one source attach a
separate sheet with details.
$
Week 4
$
Week 8
6. Other income details
Please note: you will need to provide witnessed copies of
Other income includes income received from shares, managed investments,
payslips for the past eight weeks to verify your income.
trusts, interest, rental properties.
2. Centrelink payment details
(a) Are you receiving income from any source not previously
(a) Are you receiving income payments from Centrelink?
identified in this declaration?
No
Go to 3
No
Go to 7
Yes
Payment type
Yes
Source of income
(b) Please provide details of the payment received (after tax) from
(b) Please provide details of the income earned
Centrelink in the past eight weeks, excluding payments for rent
$
per annum
assistance
Please note: you will need to provide a witnessed copy of your
$
Week 1
$
Week 5
most recent taxation return and financial statements for this
income source.
$
Week 2
$
Week 6
If you received income from more than one source attach a separate
$
Week 3
$
Week 7
sheet with details.
$
Week 4
$
Week 8
Please note: you will need to provide witnessed copies of
your income statements for the past eight weeks to verify your
income.
3. Business income details
(a) Are you involved in any type of business?
(include farming, self-employed, sole trader, partnership, sub-contractor)
No
Go to 4
Yes
Business type
continued page 4...
Page 3 of 4 SSA Multimedia Services Form F4899 ES V01 Apr 2011
Alcohol Ignition Interlock Program - Financial Assistance Scheme Application ... continued page 4 of 4
7. Bank account details
OFFICE USE ONLY
Provide details of all accounts held by you, solely or jointly, in banks,
Office stamp/declaration received:
building societies, or credit unions.
(1) Name of bank, building society or credit union
Account number
Type of account
Balance of account
Receipt number
$
(2) Name of bank, building society or credit union
Decision
Document/File ID
Account number
Type of account
Do you approved this application
Balance of account
No
$
Yes
Please note: you will need to provide witnessed copies of
statements for the last three months for all accounts held by
Reasons for the decision
you, solely or jointly.
If you have more than two accounts, attach a separate sheet with
details.
8. Declaration
I declare that the information I have provided in Part C of this application is
complete, true and correct in every detail.
I understand that failure to provide complete, true and correct information
may result in the application being refused, or if financial assistance is
granted on the basis of this information, the assistance will be withdrawn.
I authorise a departmental officer to make any enquiries considered
necessary for the purpose of this application.
Applicant/partner/parent/guardian’s signature
Date
/
/
It is an offence under the Criminal Code Act 1899 to dishonestly provide
information with the intent to defraud. The maximum penalty may include
ten years imprisonment.
Privacy statement: The Department of Transport and Main Roads (the
department) provides this form so that the applicant may apply for financial
assistance to meet the cost of fitting, maintaining and removing an approved
interlock. The information collected on Part C of this form is accessible by
authorised departmental persons and some of this information may be disclosed
to the Queensland Police Service. The department will not disclose your personal
details to any other third parties without your consent unless required by law.
Delegated person’s name
Position/title
Signature
Date
/
/
Page 4 of 4 SSA Multimedia Services Form F4899 ES V01 Apr 2011
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