Monthly Report by Retail Entity

            Name of Retail Entity:  ___________________________________________________________

Total number of Rebate Customers on the books of the retail entity on the last day of the month in respect of which the claim is being made.
	
Month of: 			Number of Rebate Customers	
Pensioner Concession Card - Centrelink		
Pensioner Concession Card - Department of Veterans’ Affairs		
Total number of Pensioner Concession Card Holders		
DVA Health Card for All Conditions (Gold Card) - TPI or a War Widow/er		
Health Care Card holders issued by Centrelink		
Queensland Seniors Card		
Asylum Seekers		
Residents in Residential Home parks and Multi Unit Residential Premises		
Total of all rebate card holders