Professional Documents
Culture Documents
Financial Hardship and Accomm Application Nov2010
Financial Hardship and Accomm Application Nov2010
When completed:
Email: vicbushfireappealfund@dhs.vic.gov.au
TO COMPLETE THIS APPLICATION PLEASE SIGN THE DECLARATION AND THE PRIVACY STATEMENT
ON PAGE 7
Yes No
I confirm that I am are not yet in permanent accommodation as a direct result of the 2009 Victorian bushfires
(I am living in temporary accommodation e.g. renting, living in a temporary village for fire affected communities,
other structures or any other temporary accommodation) and have not completed rebuilding (i.e. do not have an
occupancy permit for my rebuilt home) and do not have a signed contract to purchase an existing principle place of
residence before 13 October 2010. (please tick)
Yes No
If you did not answer YES to both of the questions above, then you are not eligible for this gift.
Applicant’s Details
Name:
Email address:
1
Bank Details (these will be used to make a payment to you if you are eligible for this gift):
Account Name:
Bank: Branch:
Please indicate your household’s income, assets, and liabilities for the last financial year.
Income
What was your household income (if any) for the last financial year?
Assets
Cash (e.g. bank accounts, insurance payments, Victorian Bushfire Appeal Fund Gifts etc)
2
What is the total value of your assets (excluding your fire affected home)?
If YES, what is the total estimated value of the assets intended to be used to meet your accommodation needs
in the next 12 months (please note that amounts over $300,000 may not be considered for the purposes of
determining your financial hardship)?
Liabilities
Determining your financial hardship involves consideration of a range of factors, including your capacity to recover,
your financial resources and your financial burdens. Your eligibility for this gift will be determined through the
answers you have provided in this application. However, as a general rule, if your current household income is over
$80,000 or your total assets minus liabilities are over $600,000, you would be considered ineligible for this gift.
If you are in this category but believe you should receive the Gift due to significant issues relating to your
exceptional financial needs as a result of your loss, you should provide further information for consideration below.
3
Expenses
Please indicate which of the following factors are causing you to experience financial hardship
(more than one may be appropriate)
Accommodation costs
Rebuilding costs
Living costs (e.g. food costs, transport, electricity, gas, or water bills)
Education costs
Other costs associated with an impairment or disability (e.g. property or vehicle modifications)
Once you have paid all the expenses listed above, what discretionary income do you have per week?
Is there anything else you would like to tell us that might assist us in assessing your application?
If so, please describe below.
4
To complete your application please ensure:
You have completed and signed the Statutory Declaration and Privacy Statement; and
You have attached all relevant supporting documents, including proof of identification with
your current address (e.g. Drivers Licence).
Please post your application to the Victorian Bushfire Appeal Fund at:
You have until 15 April 2011 to lodge a claim for this gift.
5
Information Sharing
On 10 February 2009, the Commonwealth and Victorian Governments established the Victorian Bushfire
Reconstruction and Recovery Authority (VBRRA) to oversee and coordinate the largest recovery and rebuilding
program Victoria has ever faced. The Authority works with communities to implement local rebuilding plans
to ensure each community’s economy, infrastructure and transport, environmental, and health and wellbeing
requirements and visions for the future are met. It works with communities, businesses, charities, local councils and
other government departments to implement these plans and help rebuild communities affected by the bushfires.
The Bushfire Recovery Services Unit (BRSU) in the Department of Human Services was established to help
deliver recovery services in the aftermath of the 2009 Victorian Bushfires. The BRSU includes the delivery of
bushfire housing services, the case management service, Community Service Hubs and addressing the
psychosocial needs of those impacted by the bushfires.
To assist the Victorian Bushfire Reconstruction and Recovery Authority and the Bushfire Recovery Services
Unit to target further assistance could you please estimate the total cost for your household to obtain to
permanent accommodation.
6
Statutory Declaration and Privacy Statement
I [full name]
of [address]
[occupation]
I make it with the understanding and belief that a person who makes a false declaration is liable to the
penalties of perjury, and
I understand that:
• the Victorian Bushfire Appeal Fund is collecting information in this application for the purpose of determining
my eligibility for financial assistance.
• this information will not be used without my permission for any other purpose other than determining
eligibility and verifying that the information provided is true and correct.
• if I am unable to provide this information upon request, the Victorian Bushfire Appeal Fund will be unable to
process my application.
• the Victorian Bushfire Appeal Fund may need to verify these details, and this may involve contacting councils,
insurance companies, employers, and government and non-government departments and agencies.
• I can request this information by contacting the Victorian Bushfire Appeal Fund.
• when I provide the Victorian Bushfire Appeal Fund with information about other individuals, the Victorian
Bushfire Appeal Fund relies on me to make these individuals aware that such information will or may be
provided to the Victorian Bushfire Appeal Fund as part of the application process.
• the information may be cross-checked with other applications.
Declared at
Before me,