Bus Travel Assistance Safety-Net Application
Contents
1. Postal address Please tick if the same as above Home telephone number Work telephone number Mobile telephone number 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 I f 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 v 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 m Section Type of school Name of nearest school to your house one way Map On Date Initials info road A Near2. Queensland Government DTMR Code The information on TMR use only the tear off page must ST MS S N be read before completing this form Section A to be completed by parent guardian Bus Travel Assistance Safety Net Application School Transport Assistance Scheme El Parent guardian details Application must be in the name of the concession card holder Where the student has a card in their own name the parent guardian should apply as the applicant but the person whose signature appears on the card must sign the cardholder certification at question 5 Only the parent guardian shown here will be able to alter or amend details for students listed in this application Title Family name Given name s Po 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 Note 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 qspatial information qld gov au IQAtlas More information about this website is on this form under Applying for safety net assistance
3. 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 6 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 7 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 school 6 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 For students under shared guardianship parents must decide from which address they will apply for assistance 7 Students from overseas interstate or on
4. 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 You will be advised of the outcome of your application in writing T Applications can only be accepted for the current school year O S Ifthe student changes school or address during the year or if the government assistance you receive changes you will need to f 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 Oo ras ia Eligibility This is only a brief summary Contact your nearest office or go to www translink com au schooltransport for full details N To be eligible for safety net assistance the student must be listed as a dependant on the applicant s Health Care Card issued by the Department of Human Services Pensioner Concession Card issued by the Department of Human Services Department of Veterans Affairs Pensioner Concession Card rned with Students who have a card issued in their own name as well as students under a Child Protection Order issued by the Department of 5 Communities Child Safety and Disability Services may also qualify for safety net assistance
5. 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 application 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 TRB FormsArea Form F3058 CFD V01 Aug 2015 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 Please ensure that the copy provided lists the CRN of each student applying for assistance 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 your CRN number and the CRN of each dependant you are wanting assistanc
6. 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 investigations show the student s to be ineligible understand that persons who intentionally provide false information to obtain a benefit may be liable to a 7068 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 and Training 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 person
7. 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 The Department of Education and Training 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 tear off page not to be ret Continued over page TRB Forms Area Form F3058 CFD V01 Aug 2015 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
8. al 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 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 B 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 7068 fine under Section 149 3 of the Transport Operations Passenger Transport Act Signed Date Approval Student s name Data entry details Initials
9. e for This information is obtained from your Health Care Card issued by the Department of Human Services Australian Concrement Health gt Department of uman Services Care Card CUSTOMER NAME 21 JAN RADORESS 1 201X S ee Y Signature of cardholder ey Q 111 111 111A WS PARTNER NAME X DEPENDENT 1 V gt DEPENDENT 2 6 DEPENDENT 3 This card s NOT transfer abie humae services gos au healthtarecard DEPENDENT 4 issued by Ihe Australian Government Department of Human Services on behal of DEPENDENT 5 the Department of Famiwes Mowsing Community Services and Indigenous Alary CARD START 22 JUL 201X LI Pensioner Concession Card You are required to supply your CRN number and the CRN of each dependant you are wanting assistance for This information is obtained from your Pensioner Concession Card issued by the Department of Human Services Australias Covernment OUSTOMER NAME 31 AUG as Ekparimerd of Human Services CUSTOMER 201X Signature of cardholder W K n 111 111 1 PARTNER NAME CHLDONME 11 0 humanservices gov su peesionercand CHLD TWO TH 1TT 111A tases by the Australian Gevermment Department of Hemar Services oe behal af CHLD THREE TN 1 111 111A the Departmen of Fandies Housing Community Services and Indigeroes Atai Card start 01 Jan 201X DSP Hitita This card is MOT ranstoradie Veterans Affairs Pensioner Concession Card You are required to supply your entitlement number and the en
10. er Concession Card VA Veterans Affairs Pensioner Concession Card CPO Child Protection Order Cardholder s name Assistance type CRN Entitlement number Not ded for Child as shown on card please tick v cick Order Expiry date Hcc _ Pcc _ va cpo _ Student s name Assistance type CRN Entitlement number Not needed for Child Expiry date Pae ok please tick Protection Order oe A Hcc _ Pcc _ vA _ cpo _ 2 Hcc _ Pcc _ vA _ cPo 3 Hcc _ Pec _ vA _ cPo 4 Hcc _ Pcc _ va _ cro 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 provide
11. est state primary km km kml B Nearest non state primary km km km 7 C Nearest state secondary km km km D Nearest non state secondary km km km 7 7 of the type attended Continued over page TRB Forms Area Form F3058 CFD V01 Aug 2015 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 ad Year Date of Name of the school ae as shown on card initials MIE grade birth they attend echool 1E I l km 2 of km 3 J km 4 l km refer to point 4 under Eligibility section on tear off page for details on measuring E 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 This copy must show the CRN of each student applying for assistance If you don t it may delay approval of your assistance refer Section C Assistance type HCC Health Care Card PCC Pension
12. 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 oOahwoN 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 Brochures outlining the Code of Conduct and detailing students and parents responsibilities are 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 government 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 7068 fine under Section 149 3 of the Transp
13. ort 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 translink com au schooltransport TransLink SEQ South Southport PO Box 10420 SOUTHPORT BC QLD 4215 Phone 5585 1857 Fax 5585 1858 Ipswich PO Box 631 IPSWICH QLD 4305 Phone 3813 8613 Fax 3813 8605 TransLink SEQ North Carseldine GPO Box 1412 BRISBANE QLD 4001 Phone 3863 9849 Fax 3863 9812 Mooloolaba PO Box 111 MOOLOOLABA QLD 4557 Phone 5452 1800 Fax 5452 1818 TransLink Southern Toowoomba Darling Downs PO Box 629 TOOWOOMBA QLD 4350 Phone 4639 0727 Fax 4639 0719 Roma South West PO Box 126 ROMA QLD 4455 Phone 4622 9509 Fax 4622 9533 Maryborough Wide Bay Burnett PO Box 371 MARYBOROUGH QLD 4650 Phone 4122 6115 Fax 4122 6150 TransLink Central Mackay PO Box 62 MACKAY QLD 4740 Phone 4951 8673 Fax 4951 8678 Rockhampton PO Box 5096 Red Hill ROCKHAMPTON QLD 4701 Phone 4931 1539 Fax 4922 8253 TransLink Northern Cairns PO Box 6542 CAIRNS QLD 4870 Phone 4045 7085 Fax 4045 7080 Townsville PO Box 7466 GARBUTT BC QLD 4814 Phone 4758 7544 Fax 4758 7511 TRB Forms Area Form F3058 CFD V01 Aug 2015
14. s more details about the Centrelink Confirmation eServices or on the website www humanservices gov au Signature of cardholder Date J On what days will the service be used Please tick v the days travelled specifying am pm actual times are not needed s gi First date of Total Total Is more than Do i ia a Monday Tuesday Wednesday Thursday Friday humberInumber one service 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 1 f 2 3 4 d 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 Other Date of Name of the school they attend get for this student initials birth or type applied for q E Continued over page TRB Forms Area Form F3058 CFD V01 Aug 2015 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
15. titlement number of each dependant you are wanting assistance for This information is obtained from your Veterans Affairs Card fie Australian Government PENSIONER ie Department of Veterans Affairs CONCESSION CARD Signature of Cardholder ay oy Child 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 TRB Forms Area Form F3058 CFD V01 Aug 2015 Bus Travel Assistance Safety Net Application School Transport Assistance Scheme NS 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 the processing of your form You can log onto qspatial information qld gov au IQAtlas 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
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