Use this form to request a payment plan to pay small amounts over an extended period. Information received via this online form is processed during business hours, Monday to Friday, 8:00am to 5pm. Required fields are marked with an asterisk (*) Your details Account number First name * Last name * Date of birth * Phone number * Email address Service address * Payment arrangement details How often would you like to pay? * -- Please Select --WeeklyFortnightlyMonthly What is the maximum amount you can afford to pay? * Per week, fortnight or month, depending on your selection at the previous question On what date would you like your payment arrangement to start? * Do you agree to Jacana Energy calculating the duration of your payment arrangement based on what you can afford to pay? * -- Please Select --YesNo Your current situation Are you unemployed? * -- Please Select --YesNo Have you applied for a Centrelink benefit of payment? * -- Please Select --YesNo Are you income-managed? * - Select -YesNo Centrelink payments Would you like to set up regular Centrelink deductions through Centrepay to cover your payment arrangement? We are only able to offer this option if you're not income-managed. - None -YesNo What is your Centrelink Reference Number? How much would you like to pay through your Centrepay deductions? If you want the full amount of your payment arrangement to come from your Centrepay deductions, please write 'full amount'. On what date would you like the deduction to start? What Centrelink Group Benefit would you like to use? -- Please Select --Carer AllowanceNewstart AllowanceParenting PaymentDisability Support PensionFamily Tax Benefit Do you authorise Jacana Energy to set up Centrelink payments on your behalf for the purpose of this payment arrangement? -- Please Select --YesNo Acceptances By submitting this form you agree to the following terms: * I confirm that the information provided in this form is true and accurate. I give permission to Jacana Energy to set-up a payment arrangement for my account based on the information submitted in this form. I understand that my payment arrangement can be varied as required and I agree to notify Jacana Energy immediately if my circumstances change.I understand that my payment arrangement can be varied as required and I agree to notify Jacana Energy immediately if my circumstances change. Centrelink deductions customers only I confirm that this deduction has no target amount and no end date. Australian Privacy legislation protects your personal information. I give permission for Jacana Energy to disclose my information to Services Australia for the purposes of checking my account number, billing number and amount I want to pay, and reconciling my payment deduction details. I understand that I can change or cancel my deduction at any time, and further information about Centrepay can be found online at servicesaustralia.gov.au/centrepay. CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Submit
