Victorian Bushfire Appeal Fund

Application for Financial Hardship and In Need of Permanent Accommodation Gift
Information regarding eligibility and additional application forms can be found at www.dhs.vic.gov.au/bushfireappeal or by calling 1800 180 213.

When completed: Post: Victorian Bushfire Appeal Fund GPO Box 4057 Melbourne 3001 (03) 9092 1926

Fax:

Email: vicbushfireappealfund@dhs.vic.gov.au
TO COMPLETE THIS APPLICATION PLEASE SIGN THE DECLARATION AND THE PRIVACY STATEMENT ON PAGE 7

Key Eligibility Questions
Did you receive the Rehousing and Recovery Destroyed Homes Gift (including people who were eligible under the Sole Residential Asset or Other Dwellings criteria)? (please tick) 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: Fire affected property address:

Your current (temporary) address (if different to the above):

Date of birth: Contact details

/

/

Gender:

Male

Female

Phone number: Email address:

Mobile phone number:

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Bank Details (these will be used to make a payment to you if you are eligible for this gift): Account Name: Bank: BSB: How many people are there in your household? How many people in your household have a healthcare card? Please attach a copy of the healthcare cards of household members. How many children 18 years or under are financially dependent on you? How many other people are financially dependent on you? Are you a single parent? Branch: Account Number: 1 2 3 4+

0

1

2

3

4+

0 0 Yes

1 1 No

2 2

3 3

4+ 4+

Household Income, Assets, and Liabilities
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? Less than $40,000 Between $80,001 and $120,000 Was there a reduction in your household income as a direct result of the 2009 Victorian bushfires? Between $40,001 and $80,000 Over $120,001 Yes No

If so, what was the reduction in your annual household income? Less than $10,000 Between $25,001 and $50,000 Assets Please indicate your household’s assets (if any). Property (excluding your fire affected home) Cash (e.g. bank accounts, insurance payments, Victorian Bushfire Appeal Fund Gifts etc) Financial Investments (e.g. bonds, shares, term deposits) Other (please describe below) Between $10,001 and $25,000 Over $50,001

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What is the total value of your assets (excluding your fire affected home)? Less than $100,000 Between $200,001 and $400,000 Between $600,001 and $800,000 Are any of these assets intended to be used to meet your accommodation needs in the next 12 months? For example, rebuilding your destroyed principle place of residence, purchasing an existing principle place of residence or renting. Between $100,001 and $200,000 Between $400,001 and $600,000 Over $800,001

Yes

No

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 Please indicate your household’s liabilities (if any). Mortgage Bank Loans Credit Card

Other (please describe below)

What is the total value of your household’s liabilities? Less than $100,000 Between $200,001 and $400,000 Between $600,001 and $800,000 Between $100,001 and $200,000 Between $400,001 and $600,000 Over $800,001

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.

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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) Medical treatment costs Education costs Other costs associated with an impairment or disability (e.g. property or vehicle modifications) Other? If 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 $101 and $150 Between $201 and $250 Between $51 and $100 Between $151 and $200 Over $251

Is there anything else you would like to tell us that might assist us in assessing your application? If 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 proof of identification with your current address (e.g. Drivers Licence). Please post your application to the Victorian Bushfire Appeal Fund at: Victorian Bushfire Appeal Fund GPO Box 4057 Melbourne 3001 Or fax to: (03) 9092 1926

Or email to: vicbushfireappealfund@dhs.vic.gov.au You have until 15 April 2011 to lodge a claim for this gift.

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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. Do you give permission for the information that you have provided to be shared with the Victorian Bushfire Reconstruction and Recovery Authority and the Bushfire Recovery Services Unit to assist them in helping people in their recovery efforts?

Yes

No

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.

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Statutory Declaration and Privacy Statement
I of [full name] [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 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. I agree with the stated purpose: Declared at In the State of Victoria, this Day of 20 Yes No

Signature of person making this declaration [To be signed in front of an authorised witness] Before me, [Signature of authorised witness]

[Name address and title of authorised witness]

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