TMR Form F3058 - Koala Koaches
Contents
1. OQ GOUTE Pensioner Concession Card Concession Australian Government Centrelink E You are required to supply your CRN number and the CRN of each dependant you are wanting Signature of cardholder Ng assistance for This information is obtained from your Pensioner Concession Card issued by a Centrelink wore Department of Families Community Services and Indigenous Affairs Veterans Affairs Pensioner di e ermana CARD Concession Card You are required to supply your entitlement S POO poa w number and the entitlement number of each Enay g dependant you are wanting assistance for ao This information is obtained from your Veterans ge Affairs Card Care and Protection Order You are required to supply a copy of the Authority to Care For a Child document issued by the Department of Communities Child Safety and Disability Services No additional supporting documentation will be required Page 4 of 6 TRB Forms Area Form F3058 CFD V01 Apr 2014 Bus Travel Assistance Safety Net Application School Transport Assistance Scheme NaS Ke pe The instructions must be read before completing this form Please remove this page and keep it for your records Applying for safety net assistance Complete this form if you wish to apply for safety net bus travel assistance Queensland Government Fill in all questions on the form and attach your documentary evidence If you do not it may delay the2. Apr 2014
3. s personal information including name school and current year level may appear on a bus pass created and issued at the request and discretion of the relevant bus operator Please give this completed application form to the operator providing the transport Section to be completed by the bus operator Operator s name Route number Fares based service operators to complete Note Excess fares are to be paid directly to the operator Fare for journey travelled _ TransLink Top Up Code Student name Notes Single Weekly Level Application ID 3 4 Operator s certification certify that the information provided in section B of this form is true and correct also certify that subject to the above student s meeting the eligibility criteria for safety net they qualify for assistance on my services in accordance with the School Transport Assistance Scheme understand that persons who intentionally provide false information to obtain a benefit may be liable to a 6600 fine under Section 149 3 of the Transport Operations Passenger Transport Act Signed Date Approval Student s name Data entry details Initials Notes Yes No tle 2 3 4 Approving officer s certification Input officer s certification have assessed this application in accordance with the have reviewed travel details on this applic
4. shown on card please tick pe protection Olen ai Hcc _ Pcc _ va cPo Student s name Assistance type CRN Entitlement number i Not needed for Care and Expiry date i i please tick v Protection Order pe 1 Hcc _ pcc _ va _ cro 2 Hcc _ Pcc _ vA _ cPo _ 3 Hcc _ Pcc _ vA _ cPo 4 Hcc _ Pcc _ vA _ cPo Cardholder certification Must be signed by the cardholder authorise Centrelink to confirm with the Department of Transport and Main Roads the current status of my Commonwealth Benefit and other details as they pertain to my concessional entitlement This involves electronically matching details have provided to the Participant with Centrelink or Department of Veterans Affairs DVA records to confirm whether or not am currently receiving a Centrelink or DVA benefit understand that this consent once signed is effective only for the period am a customer of the department also understand that this consent which is ongoing can be revoked any time by giving notice to the department understand if withdraw my consent will not be eligible for the assistance provided by the department A brochure is available from Centrelink that provides more details about the Centrelink Confirmation eServices or on the website www humanservices gov au Signature of cardholder Date On what days will the service be used Please tick Vv the days travelled specifying a
5. Bus Travel Assistance Safety Net Application Queensland School Transport Assistance Scheme Weed Government DTMR Code The information on TMR use only the tear off page STIMS S N must be read before completing this form Section A to be completed by parent guardian El Parent guardian details Application must be in the name of the concession card holder In cases where the student has a card issued in their own name the parent guardian should apply as the applicant but the student must sign the cardholder certification at question 5 Title Family name Given name s Your principal place of residence include property name and rural number if applicable Postcode Please also provide your registered plan and lot number This information is needed to assess eligibility Lot number Registered Plan Survey plan number The above information is needed to assess eligibility for assistance If you do not provide all information it may delay approval for transport assistance Your registered plan and lot number can be found on your rates notice Alternatively you can phone your local council and ask for this information or log onto www information qld gov au More information about this website is on this form under Applying for safety net assistance Postal address Please tick if the same as above Home telephone number Work telephone number Mobile telephone nu
6. ation with details approved school transport policies and procedures recorded in STIMS and confirm the student s is are not and certify that the student s is are entitled to the level of receiving assistance for the same journey s approved on this application Appropriate details have been accurately recorded assistance granted in accordance with the STIMS user manual Officer s signature Officer s signature Date Date entered Continued over page Page 30f6 TRB Forms Area Form F3058 CFD V01 Apr 2014 Bus Travel Assistance Safety Net Application continued Section C What supporting documentation do I need to supply NOTE A copy of supporting documentary evidence must accompany this application If you do not supply current documentary evidence processing of this application will be delayed If the student has a card in their own name and the parent guardian has a card that also lists that student please submit the application under the parent guardian s concession card Health Care Card You are required to supply 3 e or Health your CRN number and the vin eniam Care Card CRN of each dependant Signature of cardholder you are wanting assistance for This information is ON obtained from you r Health Issued by Centrelink on Sx Australian Government Ca re Ca rd issu ed by Department of Families Community Services and Indigenous Affairs Centrelink amp
7. ations show the student s to be ineligible understand that persons who intentionally provide false information to obtain a benefit may be liable to a 6600 fine under Section 149 3 of the Transport Operations Passenger Transport Act 1994 In order to assess an applicant s ongoing entitlement to assistance the department will verify student s personal details with the school attended and schools will disclose to the department updated information for that purpose By signing the certification below am authorising this exchange of information between the department and schools Signature Date Ensure that the certification at question 5 has also been signed by the cardholder Privacy statement The department collects the information on this form as authorised under the Transport Operations Passenger Transport Act to assess eligibility for bus safety net assistance These details are accessible by authorised department staff and may also be provided to the bus operator local conveyance committee and Department of Education Training and Employment staff as required Details on this form may also be given to Centrelink the Department of Veterans Affairs and Child Safety as required Your and the student s personal details will not be disclosed by the department to any other third party without your consent unless required to do so by law or for the purpose of Information Privacy Act 2009 Some of the student
8. d issued by Centrelink Department of Veterans Affairs Pensioner Concession Card Students who have a card issued in their own name as well as students under a Care and Protection Order issued by the Department of Communities Child Safety and Disability Services may also qualify for safety net assistance The following conditions also apply 1 The student must not be in receipt of any other assistance from the School Transport Assistance Scheme 2 Primary school students years prep 7 must live 3 2 kilometres or less by the shortest trafficable route from the nearest state primary school or the nearest non state school of the type attended 3 Secondary school students years 8 12 must live 4 8 kilometres or less by the shortest trafficable route from the nearest state secondary school or the nearest non state school of the type attended 4 Measuring The distance from your residential property to the school is measured by the shortest trafficable route over roads open for public use Distances are measured from the vehicle access point of your residential property alignment nearest to the school to the closest entrance to the school No measurements are made on private property In calculating this distance the single journey is used However in cases where the distance to and from school varies because of different routes for example one way roads the average distance is taken 5 Students must be enrolled at an approved
9. ear off page not to be returned with this application Continued over page Page 5of6 TRB Forms Area Form F3058 CFD V01 Apr 2014 Please read and remove this tear off page not to be returned with this application Bus passes Where bus companies issue bus passes the pass must be produced to the driver upon request Passes are not transferable Parents will be required to pay a replacement fee for lost passes Damaged passes will be replaced at a nominal fee provided the damaged pass is produced and identifiable When students cease using the bus service passes must be returned to the bus company immediately Excess fares are to be paid directly to the transport operator oa hwWN gt Code of Conduct for school bus travel The department has in place a Code of Conduct for School Students Travelling on Buses The Code applies to all students attending primary and secondary school in Queensland who use buses either to travel to and from school or for other school related activities such as excursions The Code sets out prescribed standards of behaviour and examples of how your child can meet these standards A brochure outlining the Code of Conduct and detailing students and parents responsibilities is available from your local bus operator or nearest departmental office as listed below Change of circumstances A new application form needs to be completed within seven days when a student changes school address or govern
10. m pm actual times are not needed ae Total Total Is more than Student s given Dene Monday Tuesday Wednesday Thursday Friday numberlnumber one service name as c of days of days used to get shown above bus this year am pm am pm am pm am pm am pm am pm school 3 4 Names of other students already receiving or applying for transport assistance including rail travel assistance bus travel assistance and conveyance allowance Note Do not include students listed at question 4 Type of assistance you Family name Given name one Date of Name of the school they attend get for this student initials birth or type applied for 1 2 l Continued over page Page 2 of 6 TRB Forms Area Form F3058 CFD V01 Apr 2014 Bus Travel Assistance Safety Net Application continued EJ Certification by parent guardian certify that the above information provided is true and correct and have read and agree to the conditions of travel as listed on the attachment of this application understand that am required to complete a new application within seven days should there be any change in the information contained in this application It is further understood that the department reserves the right to withdraw travel assistance and recover monies paid if investig
11. mber Email address IMPORTANT For fast processing these details should be the same as those held by the student s school EJ Reason for making this application New application Change of school Name of previous school attended Last date of enrolment Change of address Previous residential address Last date at that address Change of government gt Previous assistance type for example Health Care Card Date of change assistance f I Other gt Please provide details Date of change It is important to advise the school of any change of address If you don t it may affect your assistance Distance to nearest school by the shortest trafficable route Please tick Y what type of school s the student s attend and complete the appropriate section s below State primary Please complete section A below Non state primary Please complete section A and B below State secondary Please complete section C below include any state senior colleges Non state secondary Please complete section C and D below TMR use onl Distance Verification A Section Type of school Name of nearest school to your house one way Map On Date Initials info road A Nearest state primary km km kml B Nearest non state primary km km km C Nearest state secondary km km km 7 D Nearest non state
12. ment assistance Parents must notify the bus company and the department within seven days when a student no longer uses a particular service The department reserves the right to withdraw travel assistance and recover monies paid if investigations show the student to be ineligible Persons who intentionally provide false information to obtain a benefit may be liable to a 6600 fine under Section 149 3 of the Transport Operations Passenger Transport Act 1994 Departmental offices Please contact your nearest office for further information on the School Transport Assistance Scheme or log onto www tmr qld gov au schooltransport TransLink SEQ South TransLink Southern TransLink Central TransLink Northern Southport Toowoomba Darling Downs Mackay Cairns PO Box 10420 PO Box 629 PO Box 62 PO Box 6542 Southport BC Qld 4215 Toowoomba Qld 4350 Mackay Qld 4740 Cairns Qld 4870 Phone 5585 1857 Phone 4639 0727 Phone 4951 8673 Phone 4045 7085 Ipswich Roma South West Rockhampton Townsville PO Box 631 PO Box 126 PO Box 5096 PO Box 7466 Ipswich Qld 4305 Roma Qld 4455 Red Hill Garbutt BC 4814 Phone 3813 8613 Phone 4622 9509 Rockhampton Qld 4701 Phone 4758 7544 Phone 4931 1539 Maryborough Wide Bay Burnett TransLink SEQ North PO Box 371 Carseldine Maryborough Qld 4650 PO Box 156 Phone 4122 6115 Zillmere Qld 4034 Phone 3863 9849 Mooloolaba PO Box 111 Mooloolaba Qld 4557 Phone 5452 1800 Page 6 of 6 TRB Forms Area Form F3058 CFD V01
13. processing of your form You can log onto www information qid gov au and click on the image Queensland Atlas to access your lot and registration plan number Once in the atlas under the search tab on the left hand side of the screen at point 2 enter your address and click find The lot and plan number will display at point 3 Alternatively look at your rates notice or contact your local council to get your lot and plan number Return the completed form to your local bus operator This must be done within seven days of the student starting to travel on the bus Parents guardians will be required to pay the full cost of travel until approval is granted by the Department of Transport and Main Roads These fares are not refundable The department will advise successful applicants in writing Applications can only be accepted for the current school year If the student changes school or address during the year or if the government assistance you receive changes you will need to re apply for assistance within seven days of the change occurring You must also tell the department if the number of times the student catches the bus each week changes Eligibility This is only a brief summary Contact your nearest office or go to www tmr qid gov au schooltransport for full details To be eligible for safety net assistance the student must be listed as a dependant on the applicant s Health Care Card issued by Centrelink Pensioner Concession Car
14. school School transport assistance is available from only one address This address must be the principal place of residence of the student s parent or guardian 7 Students from overseas interstate or on student exchange programs are not eligible to receive travel assistance 8 Students attending TAFE colleges are not eligible to receive transport assistance 9 Students are only eligible to receive assistance on the designated bus service for their area Students living in an area serviced by a kilometre based school bus service are not eligible for assistance on fares based services 10 Travel assistance is not available for travel to alternative addresses or for travel to more than one school facility 11 In assessing eligibility of students the minimum frequency of travel is 20 that is two trips per week Note Year 7 students attending a Department of Education Training and Employment approved year 7 secondary pilot school will be treated as secondary students The Department of Education Training and Employment is responsible for transport assistance for students with a disability Please discuss eligibility requirements and assistance types for these students with the school attended Level of assistance The department will pay a maximum amount for eligible students direct to bus operators Parents guardians are responsible for the payment of any excess fares that apply above this amount Please read and remove this t
15. secondary km km km 7 J of the type attended Continued over page Page 1 of6 TRB Forms Area Form F3058 CFD V01 Apr 2014 Bus Travel Assistance Safety Net Application continued Names of students applying for bus travel assistance IMPORTANT Student details must match records held by school attended Family name Given name Other Male Year Date of Name of the school Distance as shown on card initials Female grade birth they attend to this M F school 2 km 3 I l km 4 I1 ve Ey Government assistance details Please provide details of the assistance type held by the applicant Each student s individual reference number must be provided as well as the applicant s card number If the student has a card in their own name and the parent guardian has a card that also lists that student please submit the application under the parent guardian s concession card You MUST supply a photocopy of current documentary evidence with your application refer section C If you don t it may delay approval of your assistance Assistance type HCC Health Care Card VA Veterans Affairs Pensioner Concession Card PCC Pensioner Concession Card CPO Care and Protection Order Cardholder s name Assistance type CRN Entitlement number as
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