Water and Sewerage Life Support Rebate Application Form

Water/sewerage accounts only

I hereby register as a customer dependant upon life support equipment.


* Required fields

Applicant details

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Application

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Account details

 
 

Equipment used

I, or a member of my household, is dependent on equipment requiring water supply.

 
 
(dd/mm/yyyy)

Authorisation

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Disclaimer

Icon Water cannot guarantee that water supplies will never be interrupted. Every endeavour is made to notify you in advance, but unplanned interruptions to supplies may also occur without warning.

If uninterrupted water supplies are essential, it is your responsibility, as the applicant, to make alternative arrangements for emergency situations.