Online Form - Financial Hardship Application

Ratepayers or Debtors experiencing financial hardship may be able to access relief from City of Busselton in the areas of rates, service charges, leases and or rental charges owed to the City from commercial or residential tenancy agreements and any other debt arising from a fee, interest or charge levied by the City. To determine whether you are eligible for consideration and to find out more about the application process, please view the FAQs below.

(Please complete this application in full.)

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You have the ability to save this form and complete it at a later date. An email will be generated and sent to the specified address.

Email Address:

Password:

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Note: Incomplete forms are kept for a period of 14 day(s), after this time the system will automatically delete your response.

Full name/s*

Is this application being lodged on behalf of a Corporate/ Community Organisation/ Body/ Group/ Club/ Business?*

What is the name of that organisation/body/group/club/business?

Applicants mailing address*

Contact Number*

Email Address*

Financial Hardship Details

Indicate the number of properties that you're seeking financial hardship for in the following categories (ie, 0/ 1/ 2/ 3/ 3+)

Rates

Commercial Lease

Self Supporting Loan

Community Organisation

Rent and/or Outgoings

Other

If you have chosen 'Other', please provide specific information on what assistance is being sought

Please enter the addresses which you would like to claim assistance for?

Which of the following are you in relation to the properties on this application?*

I am the Owner
I am the Lessee of a City of Busselton property
I am an agent representing the property owner

Confirm what capacity you are seeking financial hardship*

Recent unemployment or under employment
Sickness or recovery from sickness
Low income or loss of income
Unanticipated circumstances (ie, caring for a family member)

Please provide additional information to substantiate your claim

Additional Information & Confirmation

Please upload any relevant evidence of financial hardship

Max File Size: 10.00 MB
Allowed File Types: .avi, .doc, .docx, .gif, .jpeg, .jpg, .mov, .mp3, .mp4, .mpeg, .mpg, .pdf, .png, .ppt, .pptx, .xls, .xlsx

Are you aware that there are other assistance programs available from the State and Federal Governments?

Acknowledgement

I declare that the information I have provided in this application is correct and I am the authorised person by all owners or lessees or the organisation/body/group/club/business to lodge this application. I understand that should these statements and answers be untrue that the City of Busselton reserves the right to retrospectively revoke all waivers, discounts and assistance provided.*

I agree

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