financial hardship and accomm application nov2010

8/8/2019 Financial Hardship and Accomm Application Nov2010

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Victorian Bushfire Appeal Fund

Application for Financial Hardship and

In Need of Permanent Accommodation GiftInormation regarding eligibility and additional application orms can be ound at

www.dhs.vic.gov.au/bushfreappeal or by calling 1800 180 213.

Key Eligibility Questions

Did you receive the Rehousing and Recovery Destroyed Homes Git (including people who were eligible under theSole Residential Asset or Other Dwellings criteria)? (please tick)

Yes No

I confrm that I am are not yet in permanent accommodation as a direct result o the 2009 Victorian bushfres(I am living in temporary accommodation e.g. renting, living in a temporary village or fre aected communities,other structures or any other temporary accommodation) and have not completed rebuilding (i.e. do not have anoccupancy permit or my rebuilt home) and do not have a signed contract to purchase an existing principle place oresidence beore 13 October 2010. (please tick)

Yes No

I you did not answer YES to both o the questions above, then you are not eligible or this git.

Applicants Details

Name:

Fire aected property address:

Your current (temporary) address (i dierent to the above):

Date o birth: / / Gender: Male Female

Contact details Phone number: Mobile phone number:

Email address:

When completed:

Post: Victorian Bushfre Appeal Fund

GPO Box 4057

Melbourne 3001

Fax: (03) 9092 1926

Email: [email protected]

TO COMPLETE THIS APPLICATION PLEASE SIGN THE DECLARATION AND THE PRIVACY STATEMENT

ON PAGE 7


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Household Income, Assets, and Liabilities

Please indicate your households income, assets, and liabilities or the last fnancial year.

Income

What was your household income (i any) or the last fnancial year?

Less than $40,000 Between $40,001 and $80,000

Between $80,001 and $120,000 Over $120,001

Was there a reduction in your household income asa direct result o the 2009 Victorian bushfres?

Yes No

I so, what was the reduction in your annual household income?


Between $25,001 and $50,000 Over $50,001

Assets

Please indicate your households assets (i any).

Property (excluding your fre aected home)

Cash (e.g. bank accounts, insurance payments, Victorian Bushfre Appeal Fund Gits etc)

Financial Investments (e.g. bonds, shares, term deposits)

Other (please describe below)

Bank Details (these will be used to make a payment to you i you are eligible or this git):

Account Name:

Bank: Branch:

BSB: Account Number:

How many people are there in your household? 1 2 3 4+

How many people in your household have a healthcarecard? Please attach a copy o the healthcare cards ohousehold members.

0 1 2 3 4+

How many children 18 years or under are fnanciallydependent on you?

0 1 2 3 4+

How many other people are fnancially dependenton you?

0 1 2 3 4+

Are you a single parent? Yes No


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What is the total value o your assets (excluding your fre aected home)?


Between $200,001 and $400,000 Between $400,001 and $600,000

Between $600,001 and $800,000 Over $800,001

Are any o these assets intended to be used to meetyour accommodation needs in the next 12 months?For example, rebuilding your destroyed principle placeo residence, purchasing an existing principle place oresidence or renting.

Yes No

I YES, what is the total estimated value o the assets intended to be used to meet your accommodation needsin the next 12 months (please note that amounts over $300,000 may not be considered or the purposes odetermining your fnancial hardship)?

Liabilities

Please indicate your households liabilities (i any).

Mortgage Bank Loans Credit Card

Other (please describe below)

What is the total value o your households liabilities?


Between $200,001 and $400,000 Between $400,001 and $600,000

Between $600,001 and $800,000 Over $800,001

Determining your fnancial hardship involves consideration o a range o actors, including your capacity to recover,your fnancial resources and your fnancial burdens. Your eligibility or this git will be determined through theanswers you have provided in this application. However, as a general rule, i your current household income is over$80,000 or your total assets minus liabilities are over $600,000, you would be considered ineligible or this git.

I you are in this category but believe you should receive the Git due to signifcant issues relating to yourexceptional fnancial needs as a result o your loss, you should provide urther inormation or consideration below.


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Expenses

Please indicate which o the ollowing actors are causing you to experience fnancial hardship(more than one may be appropriate)

Accommodation costs

Rebuilding costs

Living costs (e.g. ood costs, transport, electricity, gas, or water bills)

Medical treatment costs

Education costs

Other costs associated with an impairment or disability (e.g. property or vehicle modifcations)

Other? I so, please describe below.

Once you have paid all the expenses listed above, what discretionary income do you have per week?

Less than $50 Between $51 and $100

Between $101 and $150 Between $151 and $200

Between $201 and $250 Over $251

Is there anything else you would like to tell us that might assist us in assessing your application?I so, please describe below.


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To complete your application please ensure:

You have accurately completed the application;

You have completed and signed the Statutory Declaration and Privacy Statement; and

You have attached all relevant supporting documents, including proo o identifcation withyour current address (e.g. Drivers Licence).

Please post your application to the Victorian Bushfre Appeal Fund at:

Victorian Bushfre Appeal FundGPO Box 4057Melbourne 3001

Or ax to: (03) 9092 1926

Or email to: [email protected]

You have until 15 April 2011 to lodge a claim or this git.


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Information Sharing

On 10 February 2009, the Commonwealth and Victorian Governments established the Victorian BushfreReconstruction and Recovery Authority (VBRRA) to oversee and coordinate the largest recovery and rebuildingprogram Victoria has ever aced. The Authority works with communities to implement local rebuilding plansto ensure each communitys economy, inrastructure and transport, environmental, and health and wellbeingrequirements and visions or the uture are met. It works with communities, businesses, charities, local councils andother government departments to implement these plans and help rebuild communities aected by the bushfres.

The Bushfre Recovery Services Unit (BRSU) in the Department o Human Services was established to helpdeliver recovery services in the atermath o the 2009 Victorian Bushfres. The BRSU includes the delivery obushfre housing services, the case management service, Community Service Hubs and addressing thepsychosocial needs o those impacted by the bushfres.

Do you give permission or the inormation that youhave provided to be shared with the Victorian BushfreReconstruction and Recovery Authority and the BushfreRecovery Services Unit to assist them in helping peoplein their recovery eorts?

Yes No

To assist the Victorian Bushfre Reconstruction and Recovery Authority and the Bushfre Recovery ServicesUnit to target urther assistance could you please estimate the total cost or your household to obtain topermanent accommodation.


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Statutory Declaration and Privacy Statement

I [full name]

o [address]

[occupation]

Do solemnly and sincerely declare that:

I acknowledge that this application is true and correct, and

I make it with the understanding and belie that a person who makes a alse declaration is liable to thepenalties o perjury, and

I understand that:

theVictorianBushreAppealFundiscollectinginformationinthisapplicationforthepurposeofdeterminingmy eligibility or fnancial assistance.

thisinformationwillnotbeusedwithoutmypermissionforanyotherpurposeotherthandeterminingeligibility and veriying that the inormation provided is true and correct.

ifIamunabletoprovidethisinformationuponrequest,theVictorianBushreAppealFundwillbeunabletoprocess my application.

theVictorianBushreAppealFundmayneedtoverifythesedetails,andthismayinvolvecontactingcouncils,insurance companies, employers, and government and non-government departments and agencies.

IcanrequestthisinformationbycontactingtheVictorianBushreAppealFund.

whenIprovidetheVictorianBushreAppealFundwithinformationaboutotherindividuals,theVictorianBushfre Appeal Fund relies on me to make these individuals aware that such inormation will or may beprovided to the Victorian Bushfre Appeal Fund as part o the application process.

theinformationmaybecross-checkedwithotherapplications.

I agree with the stated purpose: Yes No

Declared at

In the State o Victoria, this Day o 20

Signature o person making this declaration

[To be signed in front of an authorised witness]

Beore me,

[Signature of authorised witness]

[Name address and title of authorised witness]

financial hardship and accomm application nov2010

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