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									        LPG Vehicle Scheme Application Form (November 2008)
Important Information About the LPG Vehicle Scheme
Please read the Customer Guidelines and the Frequently Asked Questions before completing this application
form. These can be requested from the AusIndustry Hotline on 13 28 46 or found at www.ausindustry.gov.au. You
can also request these documents from any Medicare Office or Centrelink Customer Service Centre.
If you need help completing the application form or you have any enquiries regarding the processing of your claim,
please contact the AusIndustry Hotline on 13 28 46.

There are three different grants available, subject to eligibility criteria:
 1. a grant of $2,000 for the LPG conversion of a new or used petrol or diesel motor vehicle (this includes new or
     used vehicles where the conversion occurs after the vehicle is registered; and new vehicles where the LPG unit
     is fitted after manufacture but before the vehicle is registered for the first time).
 2. a grant of $1,000 for the purchase of a new motor vehicle with a LPG unit fitted at the time of manufacture, for
     vehicles purchased before 10 November 2008.
 3. a grant of $2,000 for the purchase of a new motor vehicle with an LPG unit fitted at the time of manufacture, for
     vehicles purchased on or after 10 November 2008.

We will determine which grant you are entitled to on the basis of your application information.

Completing an application
You must submit your application within 12 months from:
  the date of the LPG conversion where you convert a registered vehicle; or
  the date of purchase of the new vehicle

Please complete the form using a blue or black pen. The application form has seven (7) sections and requires the
following information from the grant applicant:
   contact details
   vehicle registration details
   personal bank account details and the name of the bank or financial institution (not credit card details)
   applicant declaration

The application form also requires information from your motor dealer or LPG conversion kit installer including:
  contact details
  ABN
  accreditation number
  vehicle details
  date of conversion or new vehicle purchase
  declaration that the information provided is correct.

Please note: Complete applications must include the following certified copies of supporting documents:
   vehicle registration papers
   proof that you have paid for the conversion of your vehicle OR proof that you have paid for a new LPG vehicle
More information on supporting documents can be found on page 2 and the Customer Guidelines.
Incomplete applications will delay payment.

Lodging an application
Completed applications can be lodged over the counter at any Medicare Office or Centrelink Customer Service
Centre. All supporting documents will be copied and certified at the Medicare Office or Centrelink Customer Service
Centre and your originals returned.
Applications can also be posted to: LPG Claim Processing Unit, G.P.O Box 1536, Adelaide SA 5001
For postal applications, please DO NOT provide original documents. Certified copies of supporting documents
must be provided. Original documents will not be returned. See the Customer Guidelines for who can certify.

LPG Vehicle Scheme Application form: November 2008                                                Page 1 of 5
Applying for the LPG Vehicle Scheme

For more information on these eligibility criteria, please see the Customer Guidelines and Frequently Asked
Questions (FAQs).

To help you fill out the application form and ensure you have completed all sections, a checklist has been provided for
you on page 3. You do not need to include the checklist with your application form.

An Applicant is Eligible if:
  you have not received a grant under the Scheme in the previous three years. Three years are calculated from:
      - the date of LPG conversion that was the subject of the previous grant; or
      - the date of purchase of the new vehicle that was the subject of the previous grant.
     where you have converted a registered vehicle to LPG, the conversion is complete and paid for.
      - you will need to show proof of payment for the parts AND installation of the LPG conversion kit
     where you have purchased a new vehicle with the LPG unit fitted before the vehicle is registered, the vehicle
      purchase is complete and paid for.
      - you will need to show proof of payment for the new LPG vehicle

A Vehicle is Eligible if:
  the vehicle was converted to LPG or the new LPG vehicle was purchased on or after 14 August 2006
  the vehicle is less than 3.5 tonnes Gross Vehicle Mass (GVM)
  for new or used vehicles registered at the date of conversion:
      - the vehicle is registered in your name at the date of LPG conversion; and
      - the vehicle is for private use at that time.
     for new vehicles fitted with a LPG unit before ever being registered:
      - you are the first registered owner of the vehicle; and
      - the vehicle is registered in your name at time of purchase and is a vehicle for private use at that time.

A vehicle for private use is:
   a vehicle which is registered under the laws of a State or Territory for private use; or
   if the laws of the State or Territory under which the vehicle is registered do not differentiate between private use
      and business use – a vehicle which the registered owner has declared on the application form for the Scheme is
      for private use


A Vehicle is NOT Eligible if:
  the vehicle is subject to a novated lease at the date of LPG conversion or the purchase of the new vehicle
  the vehicle is financed through a salary sacrifice arrangement at the date of LPG conversion or the purchase of
      the new LPG vehicle
     the vehicle is a demonstration or second-hand vehicle that was registered to a dealership at the time of
      conversion
     it is a motor scooter, tricycle or boat.
     It is authorised to travel on public roads in limited specified circumstances only, such as classic cars.


Grant Payment Arrangements

We will determine which grant you are entitled to on the basis of your application information.

You will be advised of the outcome of your grant application by letter. If you are eligible for the grant, payment will be
made to your personal account within 10 working days of submitting your complete application form.
The account must be in your name as payments can not be made into credit card accounts, commercial or third party
accounts. Joint personal accounts are accepted. Failure to supply your correct account details will delay
payment.




LPG Vehicle Scheme Application form: November 2008                                                 Page 2 of 5
Applicant checklist (to be completed by the applicant)

This checklist is to help you complete all sections of the application form and to ensure you provide the correct
supporting documents.

 Section 1: Applicant details. I have provided
      My address, contact details and date of birth
 Section 2: Motor Vehicle details. I have provided
      Motor vehicle registration number
       Vehicle VIN/Chassis number
       My motor vehicle details
 Section 3: Payment and Account details. I have provided
      My personal bank account details (not credit card details)
 Section 4: Applicant's declaration. I have
      Signed and dated the application declaration
 Section 5: Dealer/Installer details. The motor vehicle dealer or auto gas installer have provided
      Their business name & contact details
       ABN 
       Your vehicle registration number and VIN/Chassis number
       Date of conversion or new vehicle purchase
       Motor vehicle dealer license number OR LPG auto gas installer certificate number
 Section 6: Dealer/Installer Declaration. The motor vehicle dealer or auto gas installer has
      Signed and dated the Dealer/Installer declaration
 Section 7: Essential Information for Applicant and Dealer/Installer
 I have attached the following supporting documentation
      Vehicle Registration Papers (certified copy if posting) that show:
               You were the registered owner of the vehicle at the time of conversion (for vehicles that are registered
                at the time of conversion).
                If your registration has been renewed since the time of conversion, and you cannot provide that
                registration document, you can provide your current registration documents that show that the vehicle
                is registered in your name.
               That you are the registered owner of the new vehicle fitted with LPG (for vehicles fitted with LPG
                before ever being registered).
 AND
       Proof of Payment for the LPG conversion or new vehicle purchase (certified copy if posting).
       A proof of payment should be a tax invoice or equivalent and must include the following detail:
               the words ‘tax invoice’ or equivalent, stated prominently
               the name of the applicant
               the Business name and ABN of the installer/dealer
               the date of issue of the tax invoice
               a brief description of the goods or services sold
               the total price of the sales (including GST)
              evidence that payment has been made in full (e.g. stamped or marked paid in full or have $0.00
               balance owing).
       Proof of Payment for a new LPG vehicle could be a contract of sale. The document must specify that the
       vehicle has been fitted with a LPG unit and must show the signatures of both the applicant and dealer.




LPG Vehicle Scheme Application form: November 2008                                                Page 3 of 5
    For postal applications, attach all requested certified supporting documents here.
    Do not send this application until you have attached all requested certified supporting documentation.

Section 1. Applicant details (to be completed by the applicant)
Title              Given Name (s)                                       Surname


Gender M           F           Date of Birth                -           -
Street Address                                                                                      State       Postcode


Postal Address (if different to street address)                                                     State       Postcode



Daytime telephone number                             -

Section 2. Motor vehicle details (to be completed by the applicant)
Make                                        Model                                      Body type

Vehicle Registration number                 Vehicle VIN/Chassis



Section 3. Payment and account details (to be completed by the applicant)
Payments will be made by electronic funds transfer (EFT) to a nominated personal financial institution within 10
working days of submitting your complete and eligible application. The account must be in your name, payments will
not be made to credit card accounts, commercial or third party accounts. Joint personal accounts are accepted.

Account name/s                                                   Name of financial institution

Branch name                                              BSB number                      Account number
                                                                    -

Section 4. Applicant’s declaration (to be completed by the applicant)
I declare that;
  The vehicle was registered or declared for private use in my name at the time of LPG conversion or new vehicle
   purchase.
 The vehicle is not financed under a novated lease or a salary sacrifice arrangement at the time of conversion or
   new vehicle purchase.
 I have not received a LPG grant from the Commonwealth Government in the previous three years.
 All sections of this application form have been completed and I have attached the relevant certified supporting
   documents.
 I authorise the Commonwealth to access data from the Road or Traffic Authority of the State or Territory in which
   the vehicle is registered to validate registration details.
 All the information I have given in this application is complete, true and correct.
 I understand that giving false or misleading information in connection with this application is a serious offence and
   may result in a requirement to repay the grant.
Please note: You should ensure that your installer is properly accredited. Each State and Territory has its own
accreditation system. Ask your installer for accreditation/registration/certification details and check these against your
State/Territory requirements. Motor vehicle regulations in your State/Territory may require that the vehicle be
presented for inspection to an authorised inspection station within 14 days of fitting the LPG unit.

Applicant’s signature                                                           Date:           /               /

Please tick this box if you are able to be contacted for publicity purposes

LPG Vehicle Scheme Application form: November 2008                                                           Page 4 of 5
    Section 5. Dealer/Installer details (to be completed by the dealer/installer)
Was the LPG unit fitted at the time of the vehicle's manufacture? Yes                       No

Full name of dealer/installer                                        ABN
                                                                             -                 -                   -

Vehicle Registration number                              Vehicle VIN/Chassis


Business address                                                                                   State         Postcode


Motor vehicle dealer licence number OR Motor vehicle gas                     Date of LPG conversion or new vehicle
fitter's registration/licence or certificate number (depending on            purchase
State)


                                                                             If the vehicle was converted after registration, provide the
                                                                             date of LPG conversion. For new vehicles fitted with LPG
                                                                             before registration, provide the date of vehicle purchase.


     Section 6. Dealer/Installer Declaration (to be completed by the dealer/installer)
    I understand that giving false or misleading information in connection with this application is a serious offence, and I
    declare that all the information I have provided in this application is complete, true and correct. I understand that the
    Australian Government may inspect my business records that relate to installations supported by this program. I
    undertake to keep relevant records including the applicant's tax invoice in a manner that will enable the Australian
    Government to audit and verify claims under the LPG Vehicle Scheme.

    Dealer/Installer Signature                     Name of signatory (Please print)                      Date:         /         /




C
     Section 7. Essential Information for Applicant and Dealer/Installer
    Privacy and confidentiality: Applications for the LPG Vehicle Scheme will be treated as 'commercial-in-
    confidence'. Applicant information will be used to process applications and will only be publicly disclosed if the
    Commonwealth is required or permitted by law to make such a disclosure, or where it has your consent to do so.
    The Commonwealth may make limited disclosures to individuals, businesses or other organisations to verify claims
    made in applications. The Commonwealth may use any information received in applications in any other legitimate
    governmental business, including disclosure of any information to Commonwealth or State or Territory Government
    agencies, or to contractors engaged by the Commonwealth in connection with the program. The Commonwealth
    may make public the broad details of successful applications.

    The information provided on this application form will be passed to Centrelink to allow them to administer the
    payment of the LPG Vehicle Scheme grant. Limited relevant information may be disclosed to third parties to verify
    the accuracy of the information provided in your application for this grant and to assess your eligibility for payment
    and to ensure LPG regulatory requirements are met.

    Important information:
    Where a fraudulent claim arises the Australian Government may institute criminal law proceedings against those
    responsible.
    In the event of an incorrect payment of a claim the Australian Government reserves the right to recover funds paid
    through error.




    LPG Vehicle Scheme Application form: November 2008                                                       Page 5 of 5

								
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