TENANT FINANCIAL HARDSHIP FORM – RESIDENTIAL

NOTE: Prior to you completing the application, have you sought advice from the Australia Government website on
how you can be supported financially during this difficult time. More information can be viewed at
https://treasury.gov.au/coronavirus/households

TENANCY INFORMATION

Tenant Name

Address

FAMILY/LIVING SITUATION

No. of adults in household No. of dependants

How many family members have been How many family members
affected by financial hardship have been unaffected by
financial hardship
Total household income before

Total household income current

WORKING SITUATION
PLEASE NOTE: ONE APPLICATION TO BE COMPLETED PER JOB LOSS/CHANGE OF JOB CIRCUMSTANCES

My employment has been terminated:

Last day of employment: ____________________ Role and Company:_______________

I am in forced isolation due to __________________________________________________

First day of isolation: expected last day of isolation:

I will be returning to work on: ___________________________________________________

I have had my hours/income significantly reduced

I am a business owner and have had my income significantly reduced

Nature of business:_______________________________
Business name: _________________________________
Accountant name and contact details: ________________________________________
Expected for business run/to commence trading once crisis has subsided: YES/NO

FINANCIAL REQUESTS – PLEASE NOTE, RENT REQUESTS ONLY APPLIES FROM 14/7/2021

Rent Waiver OR Rent repayment plan

Pay $ __________________ per week/fortnight
Current Rent:___________________
Difference in total:____________________
Proposed reduced rent:_____________
Pay difference back by:_______________
Period of reduction:_____________________ Paying an extra $___________ per week
For a period of __________ weeks/fortnight
SUPPORTING DOCUMENATIONS:

Please provide ALL of the below:

I have attached a letter of separation or letter of hours lossed from my employer

I have attached copies of my last 4 weeks’ payslips before 26/6/2021

I have attached copies of 2 most recent payslips after 26/6/2021

I have applied for Centrelink benefits including rent assistance – Provide centrelink confirmation
Application number: Expected start date:
Rate of pay:

ALL SUPPORTING DOCUMENTATIONS ABOVE MUST BE PROVIDED WITH RETURN OF THIS

COMPLETED FORM IN ORDER FOR YOUR REQUEST TO BE PROCESSED

PLEASE SEND ALL BACK IN 1 EMAIL IN ORDER FOR IT TO BE PROCESSED

DISCLOSURE

I/We confirm that we are in true financial hardship. I/we have exhausted all options for financial aid
and make a declaration that my/our financial position has been adequately portrayed within this
application.
I/We understand that until such a time that a financial request is negotiated and/or agreed upon,
that the rent will remain the same as current, and standard procedures will apply for collection of
rent.

Signed: _________________________________ Date of Submission: ____________________

LANDLORD / AGENT APPROVAL

ONCE LANDLORD INSTRUCTIONS/APPROVAL PROVIDED, AGENT CAN SIGN ON BEHALF OF LANDLORD AND A
DULY SIGNED COPY IS TO BE RETURNED TO THE TENANT.

Office use only:

Please indicate approved arrangement from landlord.

Rent Waiver OR Rent repayment plan

Pay $ __________________ per week/fortnight
Current Rent:___________________
Difference in total:____________________
Proposed reduced rent:_____________
Pay difference back by:_______________
Period of reduction:_____________________ Paying an extra $___________ per week
For a period of __________ weeks/fortnight

Signed: _________________________________ Date of Approval: ____________________

Template Issued & Signed:

FURTHER COMMENTS:
Colemon Property Group Pty Ltd
ABN: 16 615 409 946
Shop 1, 211 Canterbury Road, Canterbury NSW 2193
02 8065 7745
info@colemon.com.au

www.colemon.com.au