Centrepay Deduction Form-0078

CENTREPAY DEDUCTION AUTHORITY (Form-0078)
Customer's Full Name
Customer's CRN
Customer's D.O.B
I authorise Services Australia to make a deduction of $ blanks each fortnight from my Disability Support Pension commencing Date.

I request to pay this amount to Skymac Pty Ltd T/A Avalon Village and Thornfield Cottages, 555-114-425-L, for Private Rent.
Option 1
I request that this deduction of $ blankscontinue until the target amount of $blank is reached.
Option 2
I request that this deduction of $ blanks continue until Date is reached.
Option 3

I confirm that this deduction has no target amount and no end date.
Australian Privacy legislation protects your personal information. I give permission for Skymac Pty Ltd T/A Avalon Village and Thornfield Cottages to disclose my information to Services Australia for the purpose of checking my account number, billing number and amount I want to pay, and reconciling my payment Deduction details.

I understand that I can change or cancel my Deduction at any time, and further information about Centrepay can be found online at servicesaustralia.gov.au/centrepay
Customer Signature

Clear
Date

DayMonthYear
Date
Should be Empty:

CENTREPAY DEDUCTION AUTHORITY (Form-0078)