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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