Download Temporary financial hardship form

Housing SA
Temporary financial hardship form
Complete this form to demonstrate you are currently experiencing financial hardship, and that you
have exhausted all reasonable avenues to alleviate your financial situation - eg asked family for
help, contacted a financial support service.
WHAT TEMPORARY FINANCIAL HARDSHIP IS
Temporary financial hardship is when you experience an exceptional or extraordinary circumstance
that significantly affects your ability to pay for essential living services - eg food, accommodation,
clothing, medical treatment, education costs. Exceptional circumstances can include:






the loss of, or a significantly reduced, primary income
serious illness or family tragedy
domestic abuse
gambling, drug or alcohol addiction
major loss of property due to a disaster - eg fire
significant household changes - eg separation, family visiting for a cultural obligation.
YOUR INFORMATION
Name:
Address:
Phone:
Customer no:
EXCEPTIONAL CIRCUMSTANCES
Give a brief explanation of the exceptional circumstances:
Provide a brief description of the type and amount of debt you have - eg $1,000 credit card:
Type:
$
Type:
$
Type:
$
Type:
$
Type:
$
Type:
$
Type:
$
Aug 2016
1
Housing SA
List any funds available to you at short notice and their amount - eg money in the bank, shares,
term deposits:
Type:
$
Type:
$
Type:
$
Type:
$
Type:
$
EXTRAORDINARY EXPENSES
Extraordinary expenses are those in addition to common household expenses - eg debt
obligations, cultural expenses, school excursion costs. List the expense and the amount spent.
$
per week
$
per week
$
per week
$
per week
$
per week
$
per week
$
per week
YOUR FINANCIAL SUPPORT SERVICE
Name and organisation of your financial support service - eg Anglicare Financial Counselling:
Name:
Phone:
Organisation:
Address:
YOUR SIGNATURE
Your signature:
Date:
OFFICE USE ONLY
Date received:
Approved / Not approved
Aug 2016
Office:
User ID:
Date:
2