ACT REVENUE OFFICE
RATES DEFERRAL (HARDSHIP) APPLICATION

Please send application to PO Box 252 CIVIC SQUARE  ACT  2608

For the circumstances in which rates may be deferred, and the effect of a deferral of rates, see the Rates Act 2004, Division 7.2 (Deferral of rates).

PLEASE USE BLOCK LETTERS

Please provide the full name and address of all owners.  If there is insufficient space please attach a separate sheet.

Full Name:	
Address:	
Contact Phone No.                                               (H)                                                (W)	

Full Name:	
Address:
(if address is the same, write AS ABOVE)	
Contact Phone No.                                               (H)                                                (W)	

Property Details

SUBURB	SECTION	BLOCK	UNIT	

Is the property your principal place of residence?	Yes	No

$

What is the estimated current market value of the property?

Are there any mortgages over the property?	Yes	No

If the answer is yes, please provide details.

Lending Institution	Amount Outstanding	Fortnightly Payment	Arrears	
	$	$	$	
	$	$	$	
	$	$	$	

Income & Employment

Are any of the applicants currently employed?	Yes	No

Applicant	Employer	Occupation	No of Years	

				

Are any of the applicants in receipt of a pension or allowance?

	Yes	No

Type of Pension/Allowance	Pension Number	Date of Effect	

			

Please provide details of your fortnightly income from all sources eg. salary, pensions/allowances, investments, rental income or board, child maintenance and bank interest.

Income Source	Fortnightly Amount	
	$	
	$	
	$	
Total Fortnightly Income	$	

Expenditure

Please provide details of your fortnightly expenditure

Food	$		Car/Transport Costs	$	
Clothing	$		Telephone	$	
Electricity/Oil/Gas	$		Credit Cards	$	
Water & Sewerage	$		Store Charge Cards	$	
Medical	$		Hire Purchase/Loans	$	
School Fees/Expenses	$		Personal Loans	$	
Insurance	$		Repairs & Maintenance	$	
Mortgage	$		Other	$	

Assets

Motor Vehicles (Including Boats, Caravans, Trailers and Motor Bikes)

Make	Model	Year	Registration	Value	
				$	
				$	
				$	

Please provide details of the current market value of any other major assets

Asset	Value	Other Assets	Value	
Shares/Bonds	$		$	
Household Furniture	$		$	
Property (other than your residence)	$		$	

Please provide bank account details (including term deposit and investment
accounts)

Financial Institution	Branch	Account Number	Balance	
			$	
			$	
			$	

Compensation and Third Party Claims
Do you have an outstanding compensation or third party	Yes	No
claim due to a work related or motor vehicle or other
injury or accident?  If Yes, please provide brief details.
___________________________________________________
___________________________________________________
___________________________________________________

Liabilities

Please provide details of Personal Loans, Credit Card liabilities etc

Financial Institution/ Organisation	Loan Amount/ Credit Limit	Balance 
Owing	Fortnightly Repayments	Arrears	
	$	$	$	$	
	$	$	$	$	
	$	$	$	$	
	$	$	$	$	
	$	$	$	$	

Dependants

Please specify the number and ages of your dependants.

Number of Dependants	Ages

Supporting Statement

Please provide details of any extenuating circumstances which you feel should be 
taken into consideration in assessing your application for deferment of rates.  If insufficient space, please attach additional statement.
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________

Deferment

Please indicate which charges you would like deferred

Rates Arrears	Current Year’s Rates

Interest	*Costs and expenses reasonably incurred by the
	Commissioner in attempting to recover the rates

* Only applicable if the ACT Revenue Office has initiated legal action to recover outstanding rates charges.

Declaration

I/We  __________________________________________________________________
(Full name of Applicants/Owners)
hereby declare that:

•	I/We wish to make an application for a deferment of rates.
•	To the best of my/our knowledge and belief the information provided in this application is true and correct.

I/We also authorise the ACT Revenue Office to verify any of the information provided in this application as appropriate with ACTEWAGL, Centrelink, Dept. of Veterans’ Affairs,
any other government department or agency, financial institutions or other organisations.

Signature                                                                                     Date:          /       /	
Signature                                                                                     Date:          /       /	
Please note that: 	1.   All applicants/owners must sign the application.
2.	Giving false or misleading information is a serious offence.
This form is Approved Form AF2004-12 under section 139C of the Taxation Administration Act 1999.