Hardship Assistance Application - Payment Arrangement (Rates/Debtor Accounts)

This form must only be completed and signed by the property/land owners/authorised representative (rates accounts) or person responsible for paying the account, or authorised representative (debtor accounts).

You can download the QPRC Financial Hardship and Assistance Policy here.

Payment Arrangement Details

Please choose your preferred arrangement and complete the relevant details. *

Payment extension and lump sum paymentPayment extension and payment planPayment plan only

Proposed payment date *

Lump sum payment amount *

Proposed payment plan start date *

Payment amount *

Frequency *

Proposed payment arrangement period (length of time) *

Less than 6 months6 months12 monthsOther

Reason for Hardship Request

Indicate why you are seeking assistance and provide details below *

Council’s COVID-19 Financial Assistance Policy provides for interest free payment arrangements for rates and charges for a maximum of 2 years for COVID-19 affected residential and business ratepayers.

Some examples of the types of ratepayers affected may include:

Residential ratepayers who lost employment
Business ratepayers whose business closed or where income substantially affected
Property owners who provide rent deferral or reduced rental arrangements to business tenants

What is the industry of your employment/business? *

How long have you been experiencing financial hardship? *

Details *

Applicant and Account Details

Full Name *

Property/Water Account Number of Debtor ID *

Email address

Contact phone (during business hours) *

Property Address *

Street address *

City *

State *

Postcode *

Lot and Plan (DP/SP) Number

Postal address same as property address

Postal address

Street address

City

State

Postcode

Financial Support and Dependants

Current employment status

Full timePart timeUnemployed Other

Other

Do you have a current Pensioner Concession Card (PCC) or receive any pension/government benefits?

YesNo

Pensioner Concession Card No. *

Date of Grant *

Other Benefit Type *

Pension/Benefit Amount *

Number of years property has been primary residence *

Have you claimed a Pensioner Concession on any other property this financial year? *

YesNo

Property Address *

Street address *

City *

State *

Postcode *

Other (please specify)

How many children do you support? *

Your children's ages *

Ownership/Residency Details

Is the property listed in this application your: *

Primary residential homeBusiness (landowner)Investment property - residentialBusiness (lessee)

ABN

Is the property rented? *

YesNo

Rates can be deferred where the property owner provides a rent deferral period for business tenants.

Type of rental *

Full-timePart-time

Monthly rental income *

Is the property you listed in this application

Owned by yourselfOwned jointly

Who is this property owned with and their relationship to you? *

Interest in Other Properties

Do you own an interest (either whole or partial) in any other property?

YesNo

Address of other property *

Street address *

Town/Locality *

Property ownership *

Owned by yourselfOwned jointly

Who is this other property owned with and what is their relationship to you?

Total property rental income received weekly for all properties listed above

Supporting documentation

The information below is recommended (if in possesion) to be attached to this application to assist Council in granting financial hardship assistance.

Copies of recent bank statements confirming the balances and transactions in the last 6 months, held in all bank, credit union or building society accounts. This should include your main transaction account where salary and/or Centrelink payments are credited toCopy of Pensioner Concession Card (PCC) where applicableCopies of letters from other utilities or mortgage provider confirming your financial hardship assistance agreement with themCopies of letters from support organisations confirming your financial hardshipProof of ownership of business where applicableCopies of lease agreements where applicableLetter from Financial Advisor confirming your financial situationCopy of severance letter or letter confirming you have been stood down without payOther relevant information you feel may assist you application

Upload your supporting documentation

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Payment arrangement declaration

I declare that I am authorised to apply for payment arrangement and I understand the conditions below:

Council can accept or renegotiate the terms of hardship assistance as per the Financial Hardship and Assistance Policy.
Further communications and/or documentation may be required to finalise this arrangement.
A formal response will be provided by Council detailing the outcome of the hardship application and/or payment arrangement.
lf the payment arrangement is not maintained and the applicant does not notify Council, the total amount outstanding becomes due and payable and will be subject to Council's debt recovery process. lnterest charges or late fees will apply. The cost of legal recovery will be charged to the rates or debtor account.
I consent to Council conducting any necessary checks to verify the information I have provided.

Signature *

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Date

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