FINANCIAL HARDSHIP APPLICATION FORM
Alternative Contact No
Employment and Income details
Are you currently employed?
*If you are currently employed, you will need to provide 2 recent payslips to support your employment details listed
Name of employer
Are you currently
If you are not currently employed, please provide the details below
Date employment ceased:
*If you are not currently employed you will need to provide a separation certificate -
- from your last employer and / or a letter from Centrelink confirming you are not employed.
Name of last employer
How much are you currently earning?
You earning this?
*You will need to provide documentation to support your income.
Are you in receipt of any Centrelink Benefits?
If yes, what sort of payment?
How much are you currently earning from centrelink benefits?
Do you have some other source of income not mentioned above?
please provide details and amount per week
Number of dependants
Add More Expenses
Circumstance impacting ability to make repayments
Are the above expenses shared?
Do you receive financial assistance from a spouse or significant other?
Please outline what change in your cicumstance has impacted your ability to maintain your current repayment schdule
Do you consider this financial difficulty will be:
How much do you consider you can afford to pay per frequency on your advance?
Has financial assistance been sought?
Have you sought any financial assistance from a suitably qualified advisor?