RATES / WATER REFUND APPLICATION
Locked Bag 155, Coffs Harbour 2450
Customer Service Centre, 2 Castle Street, Coffs Harbour
Email: Phone: (02) 6648 4000
Website: ABN 79 126 214 487
1. Details of the applicant (Ratepayer only)
It is important that Council is able to contact you if more information is required. Please give as much detail as possible.
Mr Ms Mrs Dr Other:
Given name/s / Surname
Company/organisation / ABN
Postal address
Suburb or town / State / Postcode
Daytime telephone / After hours telephone / Mobile
Email address
2. Refund Information
Property No / Property Address
Reason for Refund
Refund Amount ($) / Method of Payment of Refund
$ / Electronic Transfer Cheque
Verification of Payment – The applicant must provide the Coffs Harbour City Council with verification of the payment suchas a copy of the original receipt or a copy of a Credit Card / Bank Statement showing the Rates / Water Payment. The refund request will not be processed without this information. / Uest ssss
4. EFTPOS Bank transfer information
Banking Institution name:
BSB Number: / Bank Account number:
Account name:
5. Important Information Page 2
Payment made to wrong property – If this payment was meant for another property also owned by the applicant, please
DO NOTCOMPLETE THIS FORM.Send a written request via email to or the postal address listed above on thisform, and provide the following information: Name, Address, Phone Number, Property No of the property forwhich the Payment was intended.
Disputed Payment – If this applicant is in the process of disputing this payment with their Bank or Financial Institution,
DO NOTCOMPLETE THIS FORM. The Coffs Harbour City Council cannot take action while the payment is under dispute.
The Applicant must refer back to their Bank or Financial Institution for action.
6. Original payment verification check .
One or more of the following need to be provided in order to verify the original overpayment was made:
  • Copy of Receipt (please attach to this refund application)

  • Copy of Credit Card Statement or Bank Statement including names(s) and address (please attach to this refund application)

  • If paid by BPay, please provide a copy of using the “Print Screen” function displaying the payment details, names(s) and address (please attach to this refund application)

7. Privacy and personal information protection notice
  • this information is voluntarily required to process your request and will not be used for any other purpose without seeking your consent, or as required by law;
  • your information may comprise part of a public register related to this purpose;
  • your application will be retained in Council’s Records Management System and disposed of in accordance with the Local Government Disposal Authority;
  • your personal information can be accessed and corrected at any time by contacting this Council.

8. Applicant’s Signature/s
I declare that to the best of my knowledge all particulars supplied by me are correct and completed. I understand that inaccurate or false statements may cause my application to be delayed or rescinded.
Signature/s : …………………………………………………………………………… Date: ……/……./…….
Office Use Only
Completed by: ………………………….… Signature: ……………………………………
Authorised By: ………………….……….. Signature: ……………………………………
Rates N/A GL 10-9000-9000-15027 $ / Water N/A GL 70-9000-9000-15034 $______
Date received / Journal No / Initials

Rates/ Water Refund Application[FRM –E154] 13/06/2018