RATES – Financial Hardship Application Form Financial Hardship Application Form – Rates The personal information collected on this form is collected for the assessment of your hardship application under the Local Government Act 1989. Your information is treated confidentially and is not shared outside of the organisation. You may seek to amend the information provided in this form by contacting Council's Revenue Department on (03) 5036 2333. * indicates required field Applicant details ContactFull name*Contact phone*Contact email Residential address*Mailing address*EmploymentName of your employer or former employer*DependantsHow many dependants do you have?*i.e. Husband, wife, de facto partner, childrenConcessionsPlease note concession rebate can only be claimed on your principle place of residence.Do you have a concession or DVA card?* Yes No Card number*Are you currently claiming a concession rebate on your rates?* Yes No Property detailsI am the* Property owner Tenant Property address*Assessment number (found on your rates notice)*Additional propertiesDo you own another property in the Swan Hill Rural City Council municipality?* Yes No Do you own a property in another municipality?* Yes No Where is this property located?*Rates debtReason for your hardship application*Total amount owing on your rates*Are you able to make any payments?* Yes No How much are you able to pay?*Frequency* Weekly Fortnightly Monthly DeclarationDeclaration Info is correct* I declare that the above information is true and correct* Declaration further info may be requested* I understand that further information may be requested for this application* Full name*
