FINANCIAL HARDSHIP APPLICATION FORM
BREEZY LOANS
Personal Detail
Name
Address
Contact No
Email
Alternative Contact No
Employment and Income details
Are you currently employed?
YES
NO
*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
select
On Contract
Full time
Part time
Casual
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
Earnings
How much are you currently earning?
You earning this?
Weekly
Fortnightly
Monthly
*You will need to provide documentation to support your income.
Are you in receipt of any Centrelink Benefits?
select
Yes
No
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?
select
Yes
No
please provide details and amount per week
DEPENDANTS
Number of dependants
Expenses Breakdown
Expense Name
Cost
Applicable as
Add More Expenses
Circumstance impacting ability to make repayments
Are the above expenses shared?
Yes
No
Do you receive financial assistance from a spouse or significant other?
Yes
No
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:
short-term
long-term
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?
Yes
No
Submit Data
