Council Rates application for Financial Hardship Step 1 of 5 20% HiddenRecord ID Incremental ID Please note - this form is for the use of Northern Grampians Shire ratepayers only. Ratepayers can use this form to make an application for Financial Hardship Relief. Council will encourage ratepayers and debtors to set up a payment arrangement tailored specifically to individual needs to reduce the amount of debt owing. Please ensure that all properties for which you seek financial hardship assistance are included on this application. Are you making this application for property in Northern Grampians Shire?* Yes No Please note - this form is for the use of Northern Grampians Shire ratepayers only. Please contact your local council to find out what financial hardship provisions they have in place. Ratepayer detailsApplicant name* Given name(s) Surname Additional ratepayer name(s)If applicable, click the + button to add more ratepayer names. Email* Enter Email Confirm Email Phone*Business hours 9am to 5pmPostal address* Street Address Address Line 2 City State Post Code Property informationProperty address(s)*Click the + button to add more properties. Your rate assessment number can be found on your rate and valuation notice.Street AddressTownPostcodeRate assessment number CircumstancesReason*Provide a brief explanation as to why you are seeking assistance.Would you like referral to an independant financial counsellor?* Yes No A staff member from Council's rating team will contact you to discuss your circumstances. AcknowledgementPrivacy Collection Statement*Personal information requested on this form will only be used by council to carry out its functions and activities and will not be disclosed without your consent except where authorised by law. If you do not provide all or part of the personal information required we may not be able to process your request in an effective and efficient manner. You have the right to seek access to and correction of your personal information. I acknowledge that: I have read and understood the Privacy Collection Statement and consent to my personal information being used for the purpose specified. Submission Statement*This request can only be made by the named applicant. If you are submitting this application on behalf of another person or entity you must be duly authorised to do so. By submitting this application you are confirming that you are authorised to do so and declare that the information is correct to the best of your knowledge. I acknowledge that: I have read, understood and confirm I am complying to the above Submission Statement. HiddenAdmin fields