Application for Financial Assistance

ALL sections of the form must be completed IN FULL.
Incomplete forms will not be considered for assistance but referred to the applicant for completion.
All information in the form will be treated as confidential.

This application has been completed by:

Name

Address

Phone

Date

Email

Relationship to applicant

APPLICANT DETAILS

Name

Address

Email

Phone

Mobile

Date of Birth

Marital Status

Partners Name

Employment status of applicant

Employment status of partner

Is the applicant Aboriginal or Torres Strait Islander origin?

Yes

No

Is the applicant an Australian citizen?

Yes

No

Is English the applicants first language?

Yes

No

Does the applicant have private health insurance?

Yes

No

Does the applicant have access to Medicare benefits?

Yes

No

Does the applicant have income protection?

Yes

No

Income

Centrelink benefit

self-funded retiree

salary earner

other

If other, please explain

Relevant Cards Held

Health Care card

HCC/Pension

DVA Gold

DVA White

In relation to lodging – Please select

Do have any investments? (please explain)

Dependants / Children – Name/s (first)

Age

Has the applicant sought financial support / counselling / consulted with a social worker? (please explain)

Have you had support from Midwest Charity Begins at Home?

Please provide details of any funds raised, grants, settlements, go fund me pages, community events, or compensation awarded / pending in relation to this applicant. Please include assistance currently sought from elsewhere (i.e. other charity assistance, benefits etc.)

Does the applicant have a criminal conviction? (Please explain)

How long has the applicant been a resident in the Midwest region? (Must be a minimum of 12 months)

Please explain the diagnosis and details of current treatment.

Please explain the impact that the illness and treatment has had on current financial circumstances.

Please explain the impact that the illness and financial situation has had on the applicants social and family circumstances.

Please give a brief outline of areas and items of need if the application was to be successful and an estimated dollar value that will enable the recipient to obtain these needs.

REFEREES

To assist Midwest Charity Begins at Home Inc to make a decision as quickly as possible, we require contact details for three referees who can verify the information provided. The first referee must be your treating medical practitioner.

Please advise these referees to expect contact from us to discuss your circumstances and needs.

Referee 1 (Medical Practitioner)

Phone

Email

Referee 2

Relationship to applicant

Phone

Email

Referee 3

Relationship to applicant

Phone

Email

Please note: Midwest Charity Begins at Home committee reserves the right to make such enquiries as we consider appropriate in the assessment of your application and may contact other than those nominated.

How did you hear about Midwest Charity Begins at Home Inc?

Please confirm below:

Further direct contact(Required)

I accept that a member of the MWCBAH committee will call me to obtain further information or supporting documentation in regard to this application and I agree that I will provide as much information or documentation as requested / necessary.

Privacy(Required)

I agree to keep the sum of funds confidential as this helps respect all our recipients both past and present, including in all media interviews.

Promotional Endorsement (if application successful)(Required)

I authorize MWCBAH to use any of the information provided in my application for promotional purposes (name withheld unless specific client consent sought).

Consent(Required)

I certify that I have the consent of ‘the applicant’ in completing this application.

Photo Opportunity(Required)

I agree to provide a photo opportunity to MWCBAH at the time of the handover of the benefit

Residential Status(Required)

I am a local resident / member of the Midwest region

Liability(Required)

I understand that the recipient release from and indemnifies the Midwest Charity Begins at Home Inc committee against, all liability that may arise from unforeseen circumstances. The committee’s decision will be final and cannot be contested. No correspondence will be entered. The committee reserve the right to limit entry or amend conditions if considered necessary, without notice.

Signature (Typing your name here constitutes a digital signature)

Date

Declaration of the Applicant

I certify that all of the information given in this application is to the best of my knowledge and belief, correct and that I am the applicant / I am acting on behalf of the applicant.

Signature (Typing your name here constitutes a digital signature)

Date

If the applicant is under 18 years of age this application must be signed below by the applicant’s parent or guardian.

Your Name (Typing your name here constitutes a digital signature)

Date

Relationship to applicant

All applications will be reviewed in a timely manner at the discretion of the committee.

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