Application for Financial Hardship

Name(Required)

First Last

Email(Required)

Phone(Required)

Address of property applying for hardship:(Required)

Street Address Address Line 2 City State / Province / Region Post Code Country

Is your postal address different from above?(Required)

Yes

Postal address

Street Address Address Line 2 City State / Province / Region Post Code Country

Application details

Apply for the following concession(s) on the basis of financial hardship:(Required)

Waiver of interest penalties, and/or legal charges invoiced in respect of a Rates bill, in part or in full.

Deferral of the full payment of Rates and Charges (extension of time to pay)

Deferral of the part payment of Rates and Charges (extension of time to pay).

Please select at least one

Is this your sole or principal place of residence?(Required)

Yes

Do you receive any pensions or other government benefits?(Required)

Yes

Please provide type of pension/benefit and amount received per fortnight

Have you claimed a pensioner concession on any other property this financial year?(Required)

Yes

Please state the address of the property:

Financial information

Income (weekly unless otherwise stated)(Required)

Your average income after tax

Government benefits/pension (including family payments etc.)

All other income (eg. self employed income, interest, dividends)

Include family payments, self employed income, interest, dividends.

Employment details:

Name of your employer

Address of your employer

Assets: Home

Property address:

Current value

Amount owed to bank or financial instition for this property

Assets: Other property

Property address:

Current value

Amount owed to bank or financial instition for this property

Other assets

Funds in banks/financial institutions:

Cars/vehicles

Other personal assests (shares/superannuation)

Expenses

Average weekly expenses

Food

Household

Electricity

Mortgage/rent

Rates/levies

Gas

Phone

Motor vehicle

Petrol

Fares

Maintenance

Medical/hospital

Other insurance

Education/childcare

Credit cards

Other necessary commitments

Total weekly expenses

Amounts you owe

Home Loan - Name of bank or institution

Amount owed - Home loan/s

Other Loans - Name of bank or institution

Amount owed for other loans

Other Liabilities - Name of bank or institution

Other liabilities

Total amount owed

Does anyone contribute to paying these liabilities? (eg. your spouse/partner)

Yes

If yes, what is the contribution amount per week?

What arrangements if any are you prepared to make to pay off the amount you currently owe to council?

Additional information you would like to add to this application:

To assist with the assessment process, please attach documentary evidence to assist us to review and assess your hardship application. Please include the following:

A copy of all household bank accounts for the past three months
Tax return statments and PAYG Summaries from the last two years
Centrelink income statement no more than 30 days old (if applicable)
Child Support Agency Statement no more than 6 months old (if applicable)

You may also include one or more of the following to further support your application:

Statutory Declaration from someone familiar with your circumstance (eg. family doctor, accountant, bank officer, welfare officer, government agency)
Medical certificates or other evidence demonstrating the circumstances that have resulted in financial hardship being experienced
Evidence of loss of the main source(s) of income (eg. seperation certificate)
Evidence of qualifying for Federal Government funding assistance in response to COVID-19
Documented evidence of having sought financial counselling
Other documentation demonstrating that you are experiencing financial hardship

Council reserves the ability to request further supporting information, at any time, if deemed necessary in order to assess your application.

Please attach evidence to support your application(Required)

Drop files here or

Max. file size: 100 MB.

Privacy Statement Your personal information is held by us in accordance with the Personal Information Protection Act 2004. The Personal Information Protection Act 2004 provides that an individual may request access to, or amendment of, information held by a public authority about that individual. Council’s Privacy Policy can be found at: www.ccc.tas.gov.au/your-council/laws-governance/privacy. If you cannot find the information that you are seeking or you wish to access your personal information, please contact us on 03 6217 9500 or email us at clarence@ccc.tas.gov.au.