Errors

errors found:

warnings found:

Resume Your Saved Form

Refund Application

To resume your form please complete the following details.

Reference Code

When you saved your form you should have been provided a reference code.

Reference Code *

Security Question

Your answer to this question must match the information you previously provided.

Errors

errors found:

warnings found:

Need Assistance?

Refund Application

For enquiries relating to your Refund Application: For example questions about eligibility, application process, accepted documentation, fees and charges etc. Contact Access Canberra: Phone: 02 6207 1923 For technical assistance: For example errors in the form, issues with attaching files or submitting the form, errors when making a payment etc. Online: Call back request Phone: 13 22 81

Visit us

You are always welcome to visit us in branch for a face-to-face appointment.

ReceiptNo

ReceiptDateTime

Total

SubTotal

ServiceFee

GST

ItemList

IncludeRule

Reference Code:

For technical assistance with this form please submit a call back request via the ACT Government Feedback System or phone the Canberra Connect Contact Centre on 13 22 81.

For enquiries relating to your Refund Application please contact Access Canberra on 13 22 81.

Please resolve the following issues before proceeding

Click on an issue to go directly to the related section of the form.

errors found:

warnings found:

Request Received

Refund Application

Thank you, your submission has been received.

Next steps

You are required to complete these additional forms to finalize your request.

Your Reference Code is:

Please quote your reference code when enquiring about your submission.

For your records

Would you like a copy of this submission for your personal records?

Your email address *

Check your email

We've sent a copy of your submission to your email address ().If you didn't receive it or would like another copy, just select one of the options below.

Refund Application - Submission confirmation

Your submission has been successful. Please keep a copy of this receipt for your records.

Date and time

Reference code

Access Canberra
ABN 16 479 763 216

GPO Box 158
Canberra City 2601

Telephone: 02 6207 1923

Request type

Refund Application

Fields marked with * are required

Type of payment being refunded *

DA number *

Licence/registration number or identifier

Payment type

Reason for cancellation/refund *

Staff member completing form

Title

Given name *

Family name *

Phone *

Email *

Individual or company requesting refund

Refund Application

Fields marked with * are required

Is the payer: *

a company

an individual

Company name *

Contact person

Title

Given name *

Family name *

Phone

Mobile *

Email *

Postal address

Address line 1 *

Address line 2

Suburb *

State *

Postcode *

Site details

Refund Application

Fields marked with * are required

Suburb/District *

Section *

Block *

Unit

If you require help with suburb/district, section or block details, visit ACTMAPi.

Address line 1 *

Address line 2

Suburb *

State

Postcode *

Payment options

Refund Application

Fields marked with * are required

Would you like the refund to be paid by *

Cheque

Electronic Funds Transfer (EFT)

Account name *

BSB number *

Account number *

Postal address

Address line 1 *

Address line 2

Suburb *

State *

Postcode *

Receipt amount *

Receipt

File:

Please note: An administration fee may be deducted from the refund. For administration fees, please refer to the current Fees and charges.

Receipt number *

RAPS code *

Administration fee applicable?

Yes

Admin fee *

Refund total *

Has customer been notified?

Yes

Please contact client to advise prior to completing this form

Is the application for refund approved? *

Yes

Reason for not approving refund *

Processing officer name

Date *

Processing officer notes

Area

Access Canberra Finance

EPSDD Finance

Delegate decision

Refund approved? *

Yes

Reason for rejection

Delegate name

Date *

Processing officer notes

error(s) Found

Please touch here to resolve the first error.