Application for Financial Hardship Use this form if you are experiencing financial hardship and would like to apply for assistance paying overdue rates on your Clarence City Council rates or are a tenant of a council owned property. Name(Required) First Last Email(Required) Phone(Required)Address of property applying for hardship:(Required) Street Address Address Line 2 City State / Province / Region Post Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Is your postal address different from above?(Required) Yes No Postal address Street Address Address Line 2 City State / Province / Region Post Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Application detailsApply for the following concession(s) on the basis of financial hardship:(Required) Waiver of interest penalties, and/or legal charges invoiced in respect of a Rates bill, in part or in full. Deferral of the full payment of Rates and Charges (extension of time to pay) Deferral of the part payment of Rates and Charges (extension of time to pay). Please select at least oneIs this your sole or principal place of residence?(Required) Yes No Do you receive any pensions or other government benefits?(Required) Yes No Please provide type of pension/benefit and amount received per fortnight Have you claimed a pensioner concession on any other property this financial year?(Required) Yes No Please state the address of the property: Financial informationIncome (weekly unless otherwise stated)(Required)Your average income after taxGovernment benefits/pension (including family payments etc.)All other income (eg. self employed income, interest, dividends) Add RemoveInclude family payments, self employed income, interest, dividends.Employment details:Name of your employerAddress of your employer Add RemoveAssets: HomeProperty address:Current valueAmount owed to bank or financial instition for this property Add RemoveAssets: Other propertyProperty address:Current valueAmount owed to bank or financial instition for this property Add RemoveOther assetsFunds in banks/financial institutions:Cars/vehiclesOther personal assests (shares/superannuation) Add RemoveExpensesAverage weekly expensesFoodHouseholdElectricityMortgage/rentRates/leviesGasPhoneMotor vehiclePetrolFaresMaintenanceMedical/hospitalOther insuranceEducation/childcareCredit cardsOther necessary commitmentsTotal weekly expensesAmounts you oweHome Loan - Name of bank or institution Amount owed - Home loan/sOther Loans - Name of bank or institution Amount owed for other loansOther Liabilities - Name of bank or institution Other liabilitiesTotal amount owedDoes anyone contribute to paying these liabilities? (eg. your spouse/partner) Yes No If yes, what is the contribution amount per week?What arrangements if any are you prepared to make to pay off the amount you currently owe to council?Additional information you would like to add to this application:To assist with the assessment process, please attach documentary evidence to assist us to review and assess your hardship application. Please include the following: A copy of all household bank accounts for the past three months Tax return statments and PAYG Summaries from the last two years Centrelink income statement no more than 30 days old (if applicable) Child Support Agency Statement no more than 6 months old (if applicable) You may also include one or more of the following to further support your application: Statutory Declaration from someone familiar with your circumstance (eg. family doctor, accountant, bank officer, welfare officer, government agency) Medical certificates or other evidence demonstrating the circumstances that have resulted in financial hardship being experienced Evidence of loss of the main source(s) of income (eg. seperation certificate) Evidence of qualifying for Federal Government funding assistance in response to COVID-19 Documented evidence of having sought financial counselling Other documentation demonstrating that you are experiencing financial hardship Council reserves the ability to request further supporting information, at any time, if deemed necessary in order to assess your application.Please attach evidence to support your application Drop files here or Select files Max. file size: 100 MB. Declaration I confirm that the information provided within this Application for Financial Hardship is accurate, and there have been no misrepresentations or omissions of fact that would otherwise influence the review and decision of Clarence City Council.Privacy Statement Your personal information is held by us in accordance with the Personal Information Protection Act 2004. The Personal Information Protection Act 2004 provides that an individual may request access to, or amendment of, information held by a public authority about that individual. Council’s Privacy Policy can be found at: www.ccc.tas.gov.au/your-council/laws-governance/privacy. If you cannot find the information that you are seeking or you wish to access your personal information, please contact us on 03 6217 9500 or email us at clarence@ccc.tas.gov.au.