Gross Weekly Income Test (Attach to Application)

Recovery Financial Assistance Application–Emergency Accommodation Allowance
OFFICE USE ONLY
Applicant Reference ID / Title / Surname / Given Name / Event Name
Date of contact / ____/____/____ / Recovery Centre / Recovery Worker
Applicant satisfies Weekly Income Test
1. Applicant details
Name
as per proof of identity / Mr Mrs Miss Ms DOB ______/______/______Age ______
Family Name______Given Names______
Address / Home / Suburb / Post Code
Contact / Phone / Email
2. Details of your household
Given Name / DOB / Age / Gender / Relationship to Applicant
1.
2.
3.
4.
5.
6.
7.
Family Structure verified (Medicare card / Centrelink form)
Note: Forms to be completed to form part of Emergency Accommodation Allowance - not all forms may be required

1. Applicant Details Form
2. Gross Weekly Income Test (attach to application)
3. Essential Repairs Form OR
4. Household and Personal Items

Provide details of what arrangements the applicant has made for emergency or alternative accommodation
3. Accommodation Provider
Name of Acommodation / Address of Acommodation / Cost per night $ (GST Incl)
Maximum allowance amounts apply

NOTE: If an applicant had sought accommodation during and post emergency event and has a receipt this must be provided and attached to the application form with their application number attached.

4. Payment for approved applications

Direct Credit to Bank

Account Name
(must be correct) / BSB
(6 digits) / Account Number / Bank/ Financial Institution

Delays in transfer can occur if there are errors in the banking details provided and contact will be made with you to rectify this. Please be aware that bank deposits can take up to 5 working days, after approval.

Written advice of approvals will be sent by post, however this may be received after your payment is received.

5. Statement of property damage

Please provide details of why your home is uninhabitable

______

1. Completed by Outreach Worker

Proof of damage has been collected / Yes No
Gross Weekly Income Test form attached to this application / Yes No
Details:
Proof of ownership of goods has been confirmed / Yes No
Details:
Recommended for approval
I authorise
Outreach Worker Name:Signature: Date

1. Statement / Declaration

I/We, ______declare that the information I/we have provided is true and correct and have noted the following:

• Privacy Statement - Territory Families is collecting the information on this form to assess your application for payment under the Natural Disaster Relief and Recovery Assistance Arrangements. If you choose not to provide personal information the Agency will be unable to assess your application. Territory Families may provide personal information from this form to other Northern Territory Government and Commonwealth government agencies and community agencies that are assisting in the provision of recovery services. Identifying information collected is only used in the administration of disaster relief assistance and to assist with the provision of personal support and counselling services where necessary. Personal information will not otherwise be disclosed to any other third party without your consent, except where authorised or required by law;
• that if financial assistance is provided, then:
• payments are made on a ONCE-ONLY basis only; and
• Recovery Financial Assistance is provided in accordance with eligibility criteria and relates to an emergency event. No changes can be made once the application has been processed.
• I/we confirm that I/we have not previously applied for, or received, the Re-Establishment Payment Household and Personal Items to assist in my recovery from this disaster.

• authorise Territory Families to make any necessary enquiries of other Territory and Commonwealth agencies to establish my/our eligibility for any payment. I authorise Territory Families to provide my personal information validate information I have provided to progress relief assistance;
• agree to repay any payment or overpayment made as a result of me/us providing incorrect information or being found to be ineligible for this payment;
• understand that giving false or misleading information to obtain a benefit from the Northern Territory Government is fraudulent and may contravene the Northern Territory Criminal Code; and
• understand that Territory Families may refer cases of suspected fraud to the Northern Territory Police Service for investigation.
• I consent to photos being taken of my home and/or household goods for the purposes of verifying the details in my application.

______/__ __/______

Name and Signature of Applicant 1DateRecovery WorkerSignature

______/__ __/______

Name and Signature of Applicant 2DateRecovery WorkerSignature

Recovery Worker

I
Name:Phone:
OFFICE USE ONLY

1. Quality Check – Welfare Centre / Outreach Team Leader

Applicant’s Identification has been sighted and confirmed as true and correct / Yes No
All sections are complete / Yes No
Applicant has signed and dated the declaration / Yes No
Recovery Worker has signed and dated the declaration / Yes No
Name:Signature: Date

1. Application assessment

(Completed by Assessments and Referrals Team)
There is NO duplicate record of application or payment in the Master Tracking Spreadsheet for this applicant / Yes No
Identification Requirements are met / Yes No
Proof of residency requirements are met (at affected address) / Yes No
Proof of power interruption for >72 hours confirmed / Yes No
Supporting documentation is attached / Yes No
I certify that this assistance complies with eligibility requirements and recommend payment / Yes No
Amount per household recommended for release to applicant / $
I authorise
Name:Signature: Date

Assessor Notes: ______

1. Assessment and Referrals Team Leader

Statement:
I confirm that the application form has been completed and meets all policy requirements.
I authorise
Name:Signature: Date

1. Authorisation by Financial Delegate

Authorised Officer Statement:
I authorise and approve the recommended value made in section8. within financial delegations.
I authorise
Name:Signature: Date

1. Payments Team Check

Duplicate Payment Test conducted / Yes / No
Signature: Date:
Payment release date
Batch Number
Finance Action Officer Name

NT Recovery Financial Assistance – Emergency Accommodation Assistance

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