Please complete this application so we can assess your situation.

You can save your application at any time and submit later; simply click on the Save and Complete Later button at the bottom of the form and take note of the link generated.

Is this property registered under more than one ratepayer? *

YesNo

Applicant Details

Registered Ratepayer

First Name *

Last Name *

Telephone

Home

Mobile

Email Address

Registered Ratepayer (2)

First Name *

Last Name *

Telephone

Home

Mobile

Email Address

Property Details

Account Number *Account Number is located on the top right hand side of your rate notice.

Property Address *

Please indicate below the circumstances for your financial hardship.

Loss of employment, loss of business or reduced working capacity

Natural Disaster

Family violence or marriage breakdown

Medical/Health

Financial Inability

Other - please add detail below

Optional - Please upload supporting documentation (i.e. Letter from your doctor)

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If you wish to provide more information regarding your situation please enter here

You must select at least one financial hardship reason from above.

Are there other adults residing at the residence? *

YesNo

Please list other persons residing at the premises

Name

Age

Relationship

Occupation

Do you have the capacity to make any rate payments? *

YesNo

Please enter the proposed payment plan

Amount *

Frequency of Payment *

Start Date *

If you wish to defer your payments please explain how and when you intend to pay.

Please enter your deferral date *Please note that deferral date cannot be more than 12 months from today.

TodaysDate

DateDifference

Your deferral date is greater than 12 months, please enter a deferral date less than 12 months.

In order to assess your application, please complete the following in relation to your Income, Expenses and Assets.

Income and Expenses

INCOME

Ratepayer (1)

Occupation *

Employment status *

Please provide your last 2 payslips or last Group Certificate *

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Please provide your last 2-4 BAS Statements *

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Please provide your Centrelink documentation, Termination Payslip *

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How many dependants are in your care? *

Do you receive a Government Benefit? *

YesNo

Jobseeker

Pension (age, Disability etc)

Have you applied for a Pension Concession on your Council Rates?

If not, please refer to the following link where you can apply:

https://www.warrnambool.vic.gov.au/pension-concession

Please upload your last 2 benefit payment slips (received from Centrelink) *

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Please provide details of other benefits received

Ratepayer (2)

Occupation *

Employment status *

Please provide your last 2 payslips or last Group Certificate *

Browse

Please provide your last 2-4 BAS Statements *

Browse

Please provide your Centrelink documentation, Termination Payslip *

Browse

How many dependants are in your care? *

Do you receive a Government Benefit? *

YesNo

Jobseeker

Pension (age, Disability etc)

Have you applied for a Pension Concession on your Council Rates?

If not, please refer to the following link where you can apply:

https://www.warrnambool.vic.gov.au/pension-concession

Please upload supporting documentation

Browse

Please provide details of other benefits received

Household Income

Please enter the income details below as combined rate payers if applicable .

Frequency *

WeeklyFortnightlyMonthlyAnnually

Salary Wages (after Tax) *

Gov. Benefits (listed above) *

Property Rental Income *

Other (Dividends, Child maint.) *

Total Household Income

EXPENSES

Please enter the household expense details below as combined rate payers if applicable

Weekly Household Expenses

Fortnightly Household Expenses

Monthly Household Expenses

Annual Household Expenses

Loans and Credit Cards

Mortgage Amt. *

Personal Loans\Credit Card\Other *

Total Liabilities

Living Expenses

Rent *

Personal Expenses *(Medical/Entertainment/)

Groceries *

Car & Transport *

Utilities *

Childcare & Education *

Other Living Exp. *

Total Living Expenses

Total Loans & Credit Card Expenses

Total Expenses

Balance (Income - Expenses)

You may wish to consider seeking assistance from a qualified financial advisor or counsellor.You can access free advice through the National Debt Helpline: https://ndh.org.au/
Another useful resource is the Victorian Government Money Help website: https://moneysmart.gov.au/managing-debt/financial-counselling

ASSETS AND SAVINGS

Please enter the asset and savings details below as combined rate payers if applicable

Please provide details of any savings or assets you own (Bank accounts, term deposits, house, rental property, car, boat, caravan etc)

Bank Accounts *(Transaction\Savings\Investment)

House *

Rental\Investment Property *

Vehicles *(Cars\Boats\Caravans\Motorbikes\etc.)

Other(Shares\Cryptocurrency)

Total Assets & Savings

FINANCIAL ASSISTANCE

Have you sought financial assistance advice from a suitably qualified financial advisor? *

YesNo

Name of Financial Advisor *

Email *

Contact Number *

Council is collecting the information on this form so that it may consider your application. The information is only used by Council for this purpose and will not be disclosed unless required under law.

Acknowledgement

I declare that the information contained in this application is true and correct and:

That Council may require further supporting documentation to supplement the information provided on this application.
*

Agree to contact Council to renegotiate if unable to make the payments as defined in this form. *

Acknowledge that if payments are not made in accordance with the agreement, or Council becomes aware of the information provided being false or misleading, any arrangements will be cancelled and collection action may be taken to recover the debt.

*

Signature Ratepayer (1) *

Draw signature|Type signatureClear

Signature Ratepayer (2) *

Draw signature|Type signatureClear

Name Ratepayer 1 *

Name Ratepayer 2 *

Date *

Unable to submit your application as the deferral date entered is greater than 12 months from today's date.
Please go back to the Deferral Section of this form and enter a valid date.

Unable to submit your application as you have not entered at least one reason for financial hardship. Please go to the reason for financial hardship section and select a reason

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