Georges River Council - Online Forms

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Hardship Assistance Payment Arrangement Online Form

RATES / DEBTOR ACCOUNTS

Please complete the online form below. Else, if you wish to print the form to complete, please use this link: Hardship Assistance Request Form - Printable.

Advisory Notes

This form must only be completed and signed by the property/land owner/authorised representative (rates accounts) or person responsible to pay the account or authorised representative (debtor accounts).

Fields marked * are mandatory.

1. PAYMENT ARRANGEMENT DETAILS

Details of the balance for this application*

Outstanding balance only (For Rates - future quarterly instalments to be paid per usual due dates on 1 August, 30 November, 28 February, 31 May.)
Future instalments /Payments

Outstanding balance $:

Future instalments/Payments $:

Please tick your preferred arrangement and complete the relevant details below:*

Tick Your Preferred Arrangement Payment extension and lump sum payment
Payment extension and payment plan
Payment plan only

Payment Extension

Proposed payment extension period:*

Under 3 months
3 months
6 months
Defer Rates – eligible pensioners only

Lump Sum Payment

Lump sum payment date:*

Today

Type date, else click on calendar icon, click on a date and click the Select button.

Payment Plan

Proposed payment arrangement period:*

Less than 6 months
6 months
12 months

Proposed arrangement start date:*

Today

Type date, else click on calendar icon, click on a date and click the Select button.

Proposed arrangement end date:*

Today

Type date, else click on calendar icon, click on a date and click the Select button.

Proposed payment frequency:*

Weekly
Fortnightly
Monthly

Payment arrangement amount $:*

2. REASON FOR HARDSHIP REQUEST

Indicate why you are seeking assistance and provide details below:*

COVID-19 Impact (Business closure/Job loss)
Unemployment
Reduced Income
Injury/Illness
Separation/Divorce
Other

State the industry of your employment / business:*

How long have you been experiencing financial hardship?:*

Details:*

3. APPLICANT AND ACCOUNT DETAILS

Given Name:*

Surname:*

Customer Type:*

Rates customer
Sundry debtor

Rates Customer Reference Number (CRN):*

Company Name (if applicable):*

Debtor ID:*

Email Address:*

Ensure your details are accurately entered so Council can contact you following submission of this form.

Contact Phone:*

Ensure your details are accurately entered so Council can contact you following submission of this form.

Property Street Address:*

Suburb:*

Postcode:*

My Postal Address is different to my property address:

Postal Street Address:*

Postal Suburb:*

Postal Postcode:*

4. FINANCIAL SUPPORT AND DEPENDENTS

Current employment status:*

Full time
Part time
Unemployed

Do you have a current Pensioner Concession Card (PCC) or receive any pension/government benefits?:*

Yes
No

Do you know that Council offers eligible pensioners rebates or discounts on Council Rates? Please visit our Rebates for Pensioners page for more information and to apply.

PCC No:*

Date of Grant:*

Today

Type date, else click on calendar icon, click on a date and click the Select button.

Other Benefit Type:

Pension/Benefit Fortnightly Amount $:*

Have you claimed a Pensioner Concession on any other property this financial year?:*

Yes
No

Property address:*

Is your postal address your principle place of living?:*

Yes
No

List number of years:*

Indicate all categories of people living at the property:

Spouse
Children
Relatives
Other

Other:*

How many children do you support?:*

State their ages:*

5. OWNERSHIP / RESIDENCY DETAILS

Is the property you listed in this application your:*

Primary residential home
Business (land owner)
Investment property - residential
Business (lessee)

Type of rental:*

Full time
Part time

Monthly rental income $:*

Is the property you listed in this application:*

Owned by yourself
Joint ownership with: (state relationship, e.g. spouse)

Relationship:*

6. INTEREST IN OTHER PROPERTIES

Do you own an interest (either whole or partial) in any other property?:*

Yes (Complete property details below)
No

Property Address

Property Ownership
Owned by yourself or with (state relationship)

Financial Assistance being provided on these properties?
If yes, provide details below.

Yes
No

Total property rental income received weekly for all properties listed above: $:*

7. SUPPORTING DOCUMENTS CHECKLIST

The information below is recommended (if in possession) to be attached to an application to assist Council in granting financial hardship assistance.

NOTE - The total attachment file size limit for this form is 10MB. You have currently selected 0 MB

Bank Statements

Copies of recent bank statements confirming the balances and transactions in the last 6 months, held in all bank, credit union or building society accounts. This should include your main transaction account

Number of bank statement documents:

Confirm how many documents you will upload.

Bank Statement document 1:

Bank Statement document 2:

Bank Statement document 3:

Bank Statement document 4:

Bank Statement document 5:

Pensioner Concession Cards

Copy of Pensioner Concession Card (PCC) where applicable

Number of PCC documents:

Confirm how many documents you will upload.

PCC document 1:

PCC document 2:

PCC document 3:

PCC document 4:

PCC document 5:

Letters from other utilities or mortgage provider

Copies of letters from other utilities or mortgage provider confirming your financial hardship assistance agreement with them

Number of utility or mortgage provider documents:

Confirm how many documents you will upload.

Utility/Mortgage provider document 1:

Utility/Mortgage provider document 2:

Utility/Mortgage provider document 3:

Utility/Mortgage provider document 4:

Utility/Mortgage provider document 5:

Support organisation

Copies of letters from support organisation confirming your financial hardship

Number of support organisation documents:

Confirm how many documents you will upload.

Support organisation document 1:

Support organisation document 2:

Support organisation document 3:

Support organisation document 4:

Support organisation document 5:

Ownership of business

Proof of ownership of business where applicable

Number of business ownership documents:

Confirm how many documents you will upload.

Business ownership document 1:

Business ownership document 2:

Business ownership document 3:

Business ownership document 4:

Business ownership document 5:

Lease agreements

Copies of lease agreements where applicable

Number of lease agreement documents:

Confirm how many documents you will upload.

Lease agreement document 1:

Lease agreement document 2:

Lease agreement document 3:

Lease agreement document 4:

Lease agreement document 5:

Letter from Financial Advisor

Letter from Financial Advisor confirming your financial situation

Number of financial advisor documents:

Confirm how many documents you will upload.

Financial advisor document 1:

Financial advisor document 2:

Financial advisor document 3:

Financial advisor document 4:

Financial advisor document 5:

Severance letters

Copy of severance letter or letter confirming you have been stood down without pay

Number of severance /stood down documents:

Confirm how many documents you will upload.

Severence/Stood down document 1:

Severence/Stood down document 2:

Severence/Stood down document 3:

Severence/Stood down document 4:

Severence/Stood down document 5:

Other relevant information

Other relevant information you feel may assist in your application

Number of other documents:

Confirm how many documents you will upload.

Authorisation*

I declare that I am authorised to apply for payment arrangement and I understand the conditions below:

I agree

Council can accept or renegotiate the terms of hardship assistance as per the Debt Management and Hardship Policy.
Further communications and/or documentation may be required to finalise this arrangement.
A formal response will be provided by Council detailing the outcome of the hardship application and/or payment arrangement.
If the payment arrangement is not maintained and the applicant does not notify Council, the total amount outstanding becomes due and payable and will be subject to Council’s debt recovery process. Interest charges or late fees will apply. The cost of legal recovery will be charged to the rates or debtor account.
I consent to Council conducting any necessary checks to verify the information I have provided.

Signature

Name of Individual/Organisation:*

If applicant is company:

Name of Signatory:

Position (Director, Manager):

Signature:*

I acknowledge NSW State Laws will accept this communication as containing my signature within the meaning of the New South Wales Electronic Transactions Act 2000 No 8

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