Alcohol Ignition Interlock Program - Financial
Assistance Scheme Application
Transport Operations (Road Use Management) Act 1995
This form is to be used if you are applying for financial assistance to pay for
the costs of fitting, maintaining and removing an approved interlock under the
Alcohol Ignition Interlock Program.
While you are subject to the Alcohol Ignition Interlock Program you may only
drive a vehicle that has been fitted with an approved interlock and nominated to
the Department of Transport and Main Roads (the department), via an interlock
provider. You are responsible for all costs associated with the program.
If you are a low income earner you may be eligible for financial assistance if:
• you hold a valid Queensland driver licence endorsed with an ‘I’ condition
(you may lodge an application prior to obtaining a driver licence with an ‘I’
condition and conditional approval may be granted pending a licence being
obtained); and
• you are an Australian citizen or permanent resident; and
• the assessable income and liquid assets are below the maximum allowable
limits which apply to your circumstances; and
• you have not received financial assistance in the last five years.
Income and liquid assets must not exceed the limits detailed on the department’s
website, www.tmr.qld.gov.au. If you have a partner, their income and liquid
assets will also be assessed. If you are a dependent child, your parent(s)/
guardian(s)’s income and liquid assets will be assessed.
To help you understand this application form, listed below are the meanings of
some relevant terms —
Your liquid assets are any funds that are readily available to you, including
money in banks, building societies, or credit unions.
A dependent child is a young person, under 22 years of age, who is:
• wholly or substantially financially dependent on their parent(s)/guardian(s),
who have responsibility for the day-to-day care, welfare and development of
the young person; and
• receiving full time education at a school, college or university, if they are
aged 16 to 21; and
• not married or in a de facto relationship; and
• not receiving a Centrelink benefit in their own right.
A person is considered to be your partner if you and the person are living
together, or usually live together, and you are married or in a de facto
relationship (opposite or same-sex).
As part of assessing your application, the department will contact the State
Penalties Enforcement Registry (SPER) to determine if you have any unpaid
fines registered with SPER. It is recommended you contact SPER on
1300 365 635 to ensure any fines you may have are up to date.
For approved applicants, financial assistance will be sufficient to meet the
minimum requirements of the program in relation to the fitment, rental and
scheduled services and removal of an approved interlock. Any additional costs,
such as those incurred due to non-compliance, will not be covered.
Supporting documents
You will need to provide documents to support your application for financial
assistance —
• Evidence of your identity in the form of a witnessed copy of a Category
A identity document, such as an Australian driver licence, Australian birth
certificate, Australian citizenship certificate or naturalisation certificate, or
Australian passport. Please refer to the department’s website,
www.tmr.qld.gov.au, for a full list of accepted Category A identity
documents.
• Evidence of Australian citizenship or permanent residency, such as a
witnessed copy of your Australian birth certificate, Australian passport,
Australian citizenship certificate or Department of Immigration and
Citizenship visa (may be the same document as provided for evidence of
identity).
• Evidence of income:
–– Witnessed copies of payslips showing the last 8 weeks of income for you
and/or your partner (or your parent(s)/guardian(s) if you are a dependent
child)
–– Witnessed copies of Centrelink income statements showing the last
8 weeks of payments for you and/or your partner (or your parent(s)/
guardian(s) if you are a dependent child)
–– Details of any other income you and/or your partner (or your parent(s)/
guardian(s) if you are a dependent child) receive
• Witnessed copies of statements from all accounts held by you and/or your
partner (or your parent(s)/guardian(s) if you are a dependent child), solely or
jointly, in banks, building societies, or credit unions.
• A witnessed copy of the Commonwealth issued Health Care Card (if
applicable).
• Evidence of dependent children such as a witnessed copy of their birth
certificate, or legal or other document (for foster children), for all children
whom you state are your dependants.
• Evidence that dependent children, between the ages of 16 and 21, are
enrolled in full time education, such as a letter from the secondary school
stating that they are a full time student, or a witnessed copy of their university enrolment, or student card.
Copies of supporting documents must be signed and endorsed by an approved
witness. The witness must sign and print their full name, position title/
designation and contact details (including office stamp). The copy must be
endorsed with the words ‘I have sighted the original document and certify this
to be a true copy of the original.’
An approved witness is a person who is a:
• Doctor
• Police Officer
• Consular or Ambassadorial Officer
• Solicitor, Barrister or Judge
• Justice of the Peace or a Commissioner for Declarations
• Notary Public or a person authorised by law to witness and sign declarations
Additional information
The lodgement of this application does not guarantee it will be approved. Your
application cannot be considered at the time of lodgement. It must be forwarded
for consideration. You will be advised of the outcome.
You may lodge the application at your nearest departmental customer service
centre or mail to:
Department of Transport and Main Roads
Interlock Processing Unit
GPO Box 1412
Brisbane Qld 4001
For further information, or to obtain a copy of the Alcohol Ignition Interlock
Program - Financial Assistance Scheme Information Sheet (S4900) visit
www.tmr.qld.gov.au or call 13 23 80*.
* Higher rates apply from mobile phones or pay phones
Part A: Personal details (to be completed by the applicant)
1. Applicant’s details
Family name (please PRINT)
Given name/s (please PRINT)
Residential address
Postcode
Postal address (if same as residential, write ‘AS ABOVE’)
Postcode
Date of birth
/
Daytime phone number
/
2. Driver licence details
Do you hold or have you ever held a Queensland driver licence?
No
Yes
Driver licence number (if known)
Expiry date
/
/
Important: You must hold a valid Queensland driver licence endorsed
with an ‘I’ condition to receive financial assistance, however you may
be granted conditional approval prior to a licence being obtained.
3. Fines registered with the State Penalties Enforcement
Registry (SPER)
Do you have any unpaid fines registered with SPER?
No
Yes
Go to 4
Contact SPER to finalise the fine or enter into a
satisfactory payment arrangement
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4. Australian residency details
Are you an Australian citizen or permanent resident?
No
You are not eligible for financial assistance
Yes
Go to 5
Please note: You will need to provide a witnessed copy of evidence
of your Australian citizenship or permanent residency.
5. Health Care Card details
Do you hold a valid Commonwealth issued Health Care Card?
No
Go to 6
Yes
applicant’s parent(s)/guardian(s) only if the applicant is a
dependent child)
1. Parent/guardian’s details
Family name (please PRINT)
Given name/s (please PRINT)
Residential address
Card number
Postcode
Expiry date
/
Part B: Parent/Guardian’s details (to be completed by the
/
Postal address (if same as residential, write ‘AS ABOVE’)
Please note: You will need to provide a witnessed copy of the health
care card (front and back).
6. Relationship details
What is your current relationship status?
Postcode
Date of birth
/
Married (You and your partner both need to complete Part C of this form)
In a de facto relationship (opposite or same-sex) (You and your
partner both need to complete Part C of this form)
What is your current relationship status?
Married (You and your partner both need to complete Part C of this form)
dependent child, need to complete Part C of this form)
In a de facto relationship (opposite or same-sex) (You and
7. Dependent child details
your partner both need to complete Part C of this form)
Do you have dependent children?
Go to 8
Yes
How many dependent children are in your care?
Single or separated (You need to complete Part C of this form)
3. Dependent child details
Do you have dependent children, other than the applicant?
No
Please note: You will need to provide a witnessed copy of birth
certificates, or legal or other documents for all children who you
state are your dependants.
8. Financial dependency details
Are you a dependent child?
No
Go to 9
Yes
Your parent/guardian will need to complete Part B and
Part C of this form (If your parent/guardian has a partner they
will also need to complete Part C of this form).
9. Declaration
/
2. Relationship details
Single or separated (You, or your parent(s)/guardian(s) if you are a
No
Daytime phone number
Go to 4
Yes
How many dependent children are in your care, including
the applicant?
Please note: You will need to provide a witnessed copy of birth
certificates, or legal or other documents for all children who you
state are your dependents, including the applicant.
4. Declaration
I declare that the information I have provided in Part B of this application is
complete, true and correct in every detail.
I declare that the information I have provided in Part A of this application is
complete, true and correct in every detail.
I understand that failure to provide complete, true and correct information
may result in the application being refused, or if financial assistance is
granted on the basis of this information, the assistance will be withdrawn.
I understand that failure to provide complete, true and correct information
may result in my application being refused, or if financial assistance is
granted on the basis of this information, the assistance will be withdrawn.
I authorise a departmental officer to make any enquiries considered
necessary for the purpose of this application.
I authorise a departmental officer to make any enquiries considered
necessary for the purpose of this application, including contacting the State
Penalties Enforcement Registry.
Parent/guardian’s signature
Applicant’s signature
Date
Date
It is an offence under the Criminal Code Act 1899 to dishonestly provide
information with the intent to defraud. The maximum penalty may include
ten years imprisonment.
/
/
/
It is an offence under the Criminal Code Act 1899 to dishonestly provide
information with the intent to defraud. The maximum penalty may include
ten years imprisonment.
Privacy statement: The Department of Transport and Main Roads (the
department) provides this form so that you may apply for financial assistance
to meet the cost of fitting, maintaining and removing an approved interlock.
The information collected on Part A of this form is accessible by authorised
departmental persons and some of this information may be disclosed to the
Queensland Police Service, State Penalties Enforcement Registry and the approved
interlock provider with whom you enter into an agreement. The department will not
disclose your personal details to any other third parties without your consent unless
required by law.
/
Privacy statement: The Department of Transport and Main Roads (the
department) provides this form so that the applicant may apply for financial
assistance to meet the cost of fitting, maintaining and removing an approved
interlock. The information collected on Part B of this form is accessible by
authorised departmental persons and some of this information may be disclosed to
the Queensland Police Service. The department will not disclose personal details to
any other third parties without consent unless required by law.
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Part C: Financial declaration (to be completed by the
(b) Please provide details of the income earned from your
involvement in the business
applicant and their partner if applicable, or the applicant’s parent/
guardian and their partner if applicable)
A separate financial declaration is required for each applicable
person (applicant/applicant’s partner/applicant’s parent or
guardian/ applicant’s parent or guardian’s partner – please print
additional pages as required.
Name of person completing the financial declaration
$
per annum
Please note: you will need to provide a witnessed copy of your
most recent taxation return and business financial statements.
4. Income stream product details
An income stream product is a regular series of payments which may be
made for a lifetime or a fixed period including, allocated pension/
annuity, superannuation pension, market-lined pension/annuity.
(a) Are you receiving income from an income stream product?
I am the:
No
applicant
Yes
applicant’s partner
applicant’s parent/guardian (on whom the applicant is dependent)
$
(a) Are you currently employed?
If you received income from more than one income stream product
attach a separate sheet with details.
(Do not include self-employment – refer to section 3)
Go to 2
5. Compensation, insurance or damages payment details
Employer’s name
Address
Postcode
Phone number
No
(b) Please provide details of the income earned (after tax) from your employment in the past eight weeks
$
Week 1
$
Week 5
$
Week 2
$
Week 6
$
Week 3
$
Week 7
$
Week 4
$
Week 8
Please note: you will need to provide witnessed copies of
payslips for the past eight weeks to verify your income.
2. Centrelink payment details
Go to 6
Payment type
(b) Please provide details of the payment received
$
per annum
Please note: you will need to provide a witnessed copy of your
most recent taxation return and financial statements for this
payment.
If you received payments from more than one source attach a
separate sheet with details.
6. Other income details
Other income includes income received from shares, managed investments,
trusts, interest, rental properties.
(a) Are you receiving income from any source not previously
identified in this declaration?
(a) Are you receiving income payments from Centrelink?
No
Income from compensation, insurance or damages includes workers’
compensation, sporting injury compensation, public liability compensation,
medical negligence compensation, personal accident and sickness
insurance, income protection insurance, third party damages as a result of
a vehicle accident, damages paid to victims of crime or as a result of
criminal injuries.
(a) Are you receiving payments from compensation, insurance or
damages claims?
Yes
If you received income from more than one employer attach a
separate sheet with details.
Yes
per annum
Please note: you will need to provide a witnessed copy of your
most recent taxation return and financial statements for this
income source.
1. Employment income details
No
Income stream product type
(b) Please provide details of the income earned
applicant’s parent/guardian’s partner
Yes
Go to 5
Go to 3
No
Payment type
Yes
(b) Please provide details of the payment received (after tax) from
Centrelink in the past eight weeks, excluding payments for rent
assistance
$
Week 1
$
Week 5
$
Week 2
$
Week 6
$
Week 3
$
Week 7
$
Week 4
$
Week 8
Go to 7
Source of income
(b) Please provide details of the income earned
$
per annum
Please note: you will need to provide a witnessed copy of your
most recent taxation return and financial statements for this
income source.
If you received income from more than one source attach a separate
sheet with details.
Please note: you will need to provide witnessed copies of
your income statements for the past eight weeks to verify your
income.
3. Business income details
(a) Are you involved in any type of business?
(include farming, self-employed, sole trader, partnership, sub-contractor)
No
Yes
Go to 4
Business type
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7. Bank account details
Provide details of all accounts held by you, solely or jointly, in banks,
building societies, or credit unions.
OFFICE USE ONLY
Office stamp/declaration received:
(1) Name of bank, building society or credit union
Account number
Type of account
Balance of account
Receipt number
$
(2) Name of bank, building society or credit union
Decision
Account number
Document/File ID
Type of account
Balance of account
$
Please note: you will need to provide witnessed copies of
statements for the last three months for all accounts held by
you, solely or jointly.
Do you approved this application
No
Yes
Reasons for the decision
If you have more than two accounts, attach a separate sheet with
details.
8. Declaration
I declare that the information I have provided in Part C of this application is
complete, true and correct in every detail.
I understand that failure to provide complete, true and correct information
may result in the application being refused, or if financial assistance is
granted on the basis of this information, the assistance will be withdrawn.
I authorise a departmental officer to make any enquiries considered
necessary for the purpose of this application.
Applicant/partner/parent/guardian’s signature
Date
/
/
It is an offence under the Criminal Code Act 1899 to dishonestly provide
information with the intent to defraud. The maximum penalty may include
ten years imprisonment.
Privacy statement: The Department of Transport and Main Roads (the
department) provides this form so that the applicant may apply for financial
assistance to meet the cost of fitting, maintaining and removing an approved
interlock. The information collected on Part C of this form is accessible by
authorised departmental persons and some of this information may be disclosed
to the Queensland Police Service. The department will not disclose your personal
details to any other third parties without your consent unless required by law.
Delegated person’s name
Position/title
Signature
Date
/
/
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