Application Number

Client Number
ENERGY & WATER
HARDSHIP ASSISTANCE
Update Form

APPLICANT INFORMATION
Name								          		
Address 					  	
Phone
Postal Address 
Fax
Email

 ADDITIONAL INFORMATION

Type of housing:
House       Unit/Apartment              Caravan                Other

Ownership:
Government rental                 Private rental                Own home		Community housing               Other
Are there any people living with you?   Yes  	No
Name
Relationship to you 
Age
Their income	

Do you own a car, motor bike or any other vehicle?   Yes. Is the registration current?   yes / no 	          No
Are you currently employed?   Yes.   How long? 			No.   How long?
Occupation          		Full time	  Part-time	     Casual
Employer
Do you receive a pension or allowance?		Yes		How long?					No
Type

ADDITIONAL INFORMATION continued
Household income (per fortnight)                                  
   pension/allowance	$   
   family payment 	$   
   wage/salary 	$   
   child support 	$   
   compensation 	$   
   other 		$ 

Household expenditure (per fortnight)  
 
rent        	$		medical/chemist $
electricity       	$		school fees	 $
gas        	$		child care	 $
phone       	$		mortgage	 $
food        	$		personal loan	 $
petrol/bus fares     	$		water rates	 $
centrelink advance     $		land rates	 $
credit card      	$		insurance	 $
fines        	$		other		 $

Have your circumstances changed since you last met with the Tribunal?
        Yes. Please give brief details below.              No

Signature         Date 

ACT Civil and Administrative Tribunal - Energy and Water
GPO Box 370, CANBERRA ACT 2601   Phone: 6207 7740   Fax: 6207 7739   email: escc@act.gov.au