FINANCIAL DETAILS Dependants How many people rely on you for financial support? Fortnightly Pay after tax $ income Pension $ How much do you What financial support do you receive for your dependants for – $ receive after tax example, from a former or current partner? every two weeks Other income for example, workers compensation, interest, – $ (fortnightly)? Superannuation income, rent or board paid to you Total income $ Fortnightly Rent or board $ expenses Mortgage repayments $ How much is your Credit card and other loan repayments $ cost of living every Utilities water, gas, electricity, telephone and data $ – two weeks Food $ (fortnightly)? Travel and motor vehicle costs $ Other expenses for example, health care, child care, insurance $ – expenses $ House and land market value $ Assets – Assets are things Car or other motor vehicle market value $ – that you own or Other assets for example, money owed to you, shares, trust funds $ – partly own Total assets $ Bank account Current bank or credit union balances (total for all accounts) $ details Total balances $ Debts Amount owing on your mortgage $ Amount owing on other loans $ Credit $ Total amount owing $ limit $ Other debts for example, amount owed to businesses or individuals. – $ Tell us about each debt. Attach information about each debt. debts $ CERTIFICATION I acknowledge that: I am the person making this application the facts are true to the best of my knowledge, information and belief I am aware that it is an offence under section 136 of the Victorian Civil and Administrative Tribunal Act 1998 to provide false or misleading information relating to this application and I am aware that the maximum penalty is 6 months imprisonment or a fine of 60 penalty units. You can find out more about penalty units on the Department of Treasury and Finance website www.dtf.vic.gov.au. Enter your name to acknowledge the statements above: Date: [dd/mm/yyyy]
FINANCIAL DETAILS Dependants How many people rely on you for financial support? Fortnightly income How much do you receive after tax every two weeks (fortnightly)? Pay after tax $ Pension $ What financial support do you receive for your dependants – for example, from a former or current partner? $ Other income – for example, workers compensation, interest, Superannuation income, rent or board paid to you $ Total income $ Fortnightly expenses How much is your cost of living every two weeks (fortnightly)? Rent or board $ Mortgage repayments $ Credit card and other loan repayments $ Utilities – water, gas, electricity, telephone and data $ Food $ Travel and motor vehicle costs $ Other expenses – for example, health care, child care, insurance $ expenses $ Assets Assets are things that you own or partly own House and land – market value $ Car or other motor vehicle – market value $ Other assets – for example, money owed to you, shares, trust funds $ Total assets $ Bank account details Current bank or credit union balances (total for all accounts) $ Total balances $ Debts Amount owing on your mortgage $ Amount owing on other loans $ Credit $ Total amount owing $ limit $ Other debts – for example, amount owed to businesses or individuals. Tell us about each debt. Attach information about each debt. $ debts $ CERTIFICATION I acknowledge that: I am the person making this application the facts are true to the best of my knowledge, information and belief I am aware that it is an offence under section 136 of the Victorian Civil and Administrative Tribunal Act 1998 to provide false or misleading information relating to this application and I am aware that the maximum penalty is 6 months imprisonment or a fine of 60 penalty units. You can find out more about penalty units on the Department of Treasury and Finance website www.dtf.vic.gov.au. Enter your name to acknowledge the statements above: Date: [dd/mm/yyyy]
Application%20for%20fee%20relief%20form.docx