Application Form

Please visit our financial hardship page for more information on the application process, or to find out more about emergency assistance and support services.

1Owner/ratepayer Information

2Property Information

3Financial Hardship

4Income and Expenditure

5Dependents

6Payment Proposal

7Supporting Documentation

8Declaration

Owner/ratepayer Information
Are you the sole owner/co-owner/ratepayer of the property?*
- Yes
- No
Surname*
Given Name(s)*
Company Name (if applicable)
Email*
Mobile Number*
Phone Number
Residential Address*
Street Address Address Line 2 Town / City State Postal Code Country
Postal Address*
Same as residential address

Street Address Address Line 2 Town / City State Postal Code Country

Property Information
Assessment Number*
Property Address*
Street Address Address Line 2 Town / City State Postal Code Country
What is the property’s rates account balance?*
Is the property owner/occupied or is it a rental?*
- owner occupied
- rental
Who is the managing agent?*
What is the lease type?*

Income and Expenditure
Form of Income
Annual Amount
Wage and Salaries *
Amount per Year*
Pension or other government benefits
Amount per Year
Spouse or partners income
Amount per Year
Interest from banks and financial institutions or dividends
Amount per Year
Compensation, superannuation insurance or retirement benefits
Amount per Year
Have you received any other income?
Type of payment
Amount per Year
Type of payment
Amount per Year
Type of payment
Amount per Year
Total Income
Outgoing Expenditure
Provider Name
Annual Amount
Mortgage / Home loan *
Provider Name*
Amount per Year*
Other mortgages / business loans
Provider Name
Amount per Year
Other loans
Provider Name
Amount per Year
Credit Cards
Provider Name
Amount per Year
Power *
Provider Name*
Amount per Year*
Water *
Provider Name*
Amount per Year*
Rates *
Provider Name*
Amount per Year*
Phone
Provider Name
Amount per Year
Insurances *
Provider Name*
Amount per Year*
Living Expenses *
Provider Name*
Amount per Year*
Do you have any other outgoing expenditure?
Type of expenditure
Amount per Year
Type of expenditure
Amount per Year
Type of expenditure
Amount per Year
Total Expenditure
Total Balance (Total income, less total expenditure)

Dependents
Please indicate any dependents you are supporting
- Spouse / Partner
- Children
- Other
Number of dependent children
Please provide details of other dependants you are supporting

Payment Proposal
Amount*
What is the payment amount and frequency you can afford to commit to?
Frequency*

Supporting Documentation
Upload documentation*
To assist us with your application, please provide on lodgment the relevant documentation to support your financial hardship application.
Maximum number of uploads: 10,
Allowed file extensions: pdf, jpg, jpeg, png
Maximum file size: 1MB.
Drop files here or

Accepted file types: pdf, jpg, jpeg, png, Max. file size: 1 MB, Max. files: 10.
Confirm Uploaded Documents*
- Bank Statement/s
- Medical Certificate
- Centrelink
- Letter from employer
- Letter from a Provider who has deemed you to be experiencing financial hardship (e.g. bank, super fund, utilities)
- Letter from an authorised financial counsellor or planner confirming financial hardship
- Letter from an authorised financial counsellor or planner confirming financial hardship
- Documentation such as a statutory declaration from a person familiar with your financial circumstances (e.g. family doctor, accountant).

Declaration
Consent*
I confirm that the information provided within this Application for Financial Hardship is accurate, and there have been no misrepresentations or omissions of fact that would otherwise influence the review and decision of the Shire of Mingenew.*
Consent*
I declare that I am the ratepayer and authorised person of the above-mentioned property.*
Signature*
Please click on the box below to draw your signature
Phone
This field is for validation purposes and should be left unchanged.

Application Form

Important Information

This form requires multiple supporting documents to be uploaded for lodgement.

Owner/ratepayer Information

Property Information

Financial Hardship

Income and Expenditure

Form of Income

Annual Amount

Wage and Salaries *

Pension or other government benefits

Spouse or partners income

Interest from banks and financial institutions or dividends

Compensation, superannuation insurance or retirement benefits

Have you received any other income?

Outgoing Expenditure

Provider Name

Annual Amount

Mortgage / Home loan *

Other mortgages / business loans

Other loans

Credit Cards

Power *

Water *

Rates *

Phone

Insurances *

Living Expenses *

Do you have any other outgoing expenditure?

Dependents

Payment Proposal

Supporting Documentation

Declaration

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