Online Form - Financial Hardship Application

The Shire of Denmark recognises that at times there could be cases of genuine financial hardship, where debtors (sundry and rates) will experience difficulty in paying fees, rates and service charges as they fall due. The Shire of Denmark has adopted a Financial Hardship Policy and this applies to all debtors (sundry and rates) experiencing genuine financial hardship in relation to:

Outstanding fees, rates and services; and
Future fees, rates and service charges levied.

Applicant 1: Full Name*

Postal Address

Street Address:*

City:*

State:*

Post Code:*

Country:*

Phone*

Email*

Applicant 2 (if applicable): Full Name

Postal Address Same as Above?*

YesNo

Postal Address (if applicable)

Street Address:

City:

State:

Post Code:

Country:

Phone*

Email*

Property Details: Account Number*

Property Address

Street Address:*

City:*

State:*

Post Code:*

Country:*

Is this application being lodged on behalf of a Body Corporate or community organisation?*

YesNo

Please describe your reason for experiencing financial hardship*

Repayment Arrangement Proposal: What is the TOTAL AMOUNT OWNING?*

Repayment Arrangement Proposal: What PAYMENT PLAN AMOUNT can you afford to commit to?*

Repayment Arrangement Proposal: What is the FREQUENCY of repayments you can afford to commit to?*

Repayment Arrangement Proposal: What is the PROPOSED END DATE you could commit to?*

Supporting Documentation: This application must be accompanied by a copy of a financial hardship letter from a qualified financial body (i.e. a fully accredited member of Financial Counsellors Association of Western Australia or Bank). By providing this document, the applicant authorises the Shire of Denmark to reproduce this document for internal purposes only.*

Max File Size: 10.00 MB
Allowed File Types: .avi, .doc, .docx, .gif, .jpeg, .jpg, .mov, .mp3, .mp4, .mpeg, .mpg, .pdf, .png, .ppt, .pptx, .xls, .xlsx

Declaration: By submitting this document, the applicant/s understand that they are hereby declaring that they are experiencing financial hardship, are not bankrupt or subject to a bankruptcy petition and will advise the Shire of Denmark if there is any change to their financial circumstances.*

YesNo