Phone number Email Hours requested funds requested $ (Ex. GST) Please ensure you know and understand your provider’s costs including weekend and public holiday rates. . Section 7 - Declaration To be completed by the primary carer or case manager All personal and health information collected will be treated confidentially and will only be used for the purposes of assessing eligibility for this service and service provision. By signing this form you: Declare that information you have supplied on this application is correct. Agree that you have read the above information that you have read the program guidelines Understand this is an application for respite funding. Funding is not guaranteed. Breakaway Funding Period Application to be Application Purchase sent Letter sent to (All allocations valid for 3 months) in by COB Processed by to provider by applicant by 1st August 31st October 10th July 20th July 25th July 28th July – 1st September 30th November 10th Aug 20th Aug 25th Aug 28th Aug – 1st October 31st December 10th Sept 20th Sept 25th Sept 28th Sept – 1st November 31st January 10th Oct 20th Oct 25th Oct 28th Oct – 1st December 28th February 10th Nov 20th Nov 25th Nov 28th Nov – 1st January 31st March 10th Dec 20th Dec 25th Dec 28th Dec – 1st February 30th 10th Jan 20th Jan 25th Jan 28th Jan – 1st March 31st May 10th Feb 20th Feb 25th Feb 28th Feb – 1st April 30th June 10th Mar 20th Mar 25th Mar 28th Mar – 1st May 31st July 10th Apr 20th Apr 25th Apr 28th Apr – 1st June 31st August 10th May 20th May 25th May 28th May – 1st July 30th September 10th June 20th June 25th June 28th June – Primary Name Signature Date Section 8 Breakaway Dates –
Phone number Email Hours requested funds requested (Ex. GST) $ Please ensure you know and understand your provider’s costs including weekend and public holiday rates. . Section 7 - Declaration To be completed by the primary carer or case manager Breakaway Funding Period (All allocations valid for 3 months) Application to be in by COB Application Processed by Purchase sent to provider by Letter sent to applicant by 1st August – 31st October 10th July 20th July 25th July 28th July 1st September – 30th November 10th Aug 20th Aug 25th Aug 28th Aug 1st October – 31st December 10th Sept 20th Sept 25th Sept 28th Sept 1st November – 31st January 10th Oct 20th Oct 25th Oct 28th Oct 1st December – 28th February 10th Nov 20th Nov 25th Nov 28th Nov 1st January – 31st March 10th Dec 20th Dec 25th Dec 28th Dec 1st February – 30th 10th Jan 20th Jan 25th Jan 28th Jan 1st March – 31st May 10th Feb 20th Feb 25th Feb 28th Feb 1st April – 30th June 10th Mar 20th Mar 25th Mar 28th Mar 1st May – 31st July 10th Apr 20th Apr 25th Apr 28th Apr 1st June – 31st August 10th May 20th May 25th May 28th May 1st July – 30th September 10th June 20th June 25th June 28th June All personal and health information collected will be treated confidentially and will only be used for the purposes of assessing eligibility for this service and service provision. By signing this form you: Declare that information you have supplied on this application is correct. Agree that you have read the above information that you have read the program guidelines Understand this is an application for respite funding. Funding is not guaranteed. Primary Name Signature Date Section 8 – Breakaway Dates