Application for

NATURAL DISASTER RELIEF & RECOVERY GRANT

PRIMARY PRODUCERS

Banana & Shellfish sectors only

JUNE 2016 EAST COAST STORMS AND FLOODS

Applications should be returned to:

NSW Rural Assistance Authority

Locked Bag 23

ORANGE NSW 2800

Application must be received by the NSW Rural Assistance Authority

on or before 8 May 2017

CHECK LIST

To avoid any delay in the processing of your application, please complete the following checklist.
Have you attached the required documents with this claim?
Proof of property location(Copy of last Local Government Area and Local Land Services rate notices)
(Applicants in the aquaculture industry may supply other evidence to confirm proof of location)
Proof of income(Copy of latest available Primary Production Enterprise Taxation Returns and Financial Statements plus Personal Tax Returns of all members of the Business Enterprise)
DO NOT SEND TAX ASSESSMENT NOTICES
Proof of Expenditure(Copies of Tax Invoice/Receipts or Quotes)
Proof of Insurance(Copy of Insurance Claim)
Did you answer all the questions and include the following information?
Business ABN number
Copy of existing Fishing Business Determination Certificate/s (Commercial Fishers only)
Bank account details
Did you sign and date the statement and consent on pages 3 and 4?
Have you applied previously for assistance from the NSW Rural Assistance Authority? / Yes No
NOTE: If you select ‘Yes’ please provide your 6 digit BP number, if available. / BP:
  1. About you

Applicant(s) Full Name(s) : / Date(s) of Birth
/ /
/ /
Full Property Address:
Postcode
Local Government Area of Property:
Local Land Services area of Property:
Postal Address (If different to property address)
Postcode
Contact Numbers:
Phone: / Mobile: / Fax:
E-mail:
How would you like to receive future correspondence from the RAA?
Mail Facsimile Email (Please Tick)
  1. About your primary production enterprise

Type of primary production enterprise e.g. bananas, oysters, poultry, beef:
Details of your primary production enterprise.
Trading name if different from the legal / registered name:
ABN: / ACN:
Do you earn more than 51% of your gross income from the farm? / Yes No
NOTE: If ‘No’ you are not eligible to apply for this grant
Have you applied previously, or are you a partner, or do you have any financial involvement with any other primary production business applying for a Natural Disaster Relief and Recovery Grant? / Yes No
If yes, please provide details below.
Family Name :
Given name(s) :
Business name :
Role in the business :
Do you intend to continue the primary production enterprise? / Yes No
  1. Reason for claiming

Has this business suffered direct damage as a result of the June 2016 East Coast Storms and Floods? / Yes No
Briefly describe the damage claimed NOT covered by insurance.
What is the estimated value of the damage? / $
What is the Amount of Grant applied for? (Maximum - $10,000) / $
Has a claim for insurance been made as a result of the June 2016 East Coast Storms and Floods? / Yes No
If No, please advise why a claim has not been made.

If Yes, please provide a copy of your insurance claim.

  1. Bank Account details

Please provide bank account details for payment of grant

Account Name :
Bank/Credit Union etc Name :
BSB : / Account No:
  1. Contact Details

Accountant
Firm Name:
Contact Name:
Phone:
/ Mobile: / Fax:
E-mail:
Rural Financial Counsellor
Counselling Service Name:
Contact Name:
Phone:
/ Mobile: / Fax:
E-mail:
  1. Consent for release of information

I/We have lodged a claim with the NSW Rural Assistance Authority for a Natural Disaster Relief and Recovery Grant for primary producers in relation to the June 2016 East Coast Storms and Floods.

To allow this claim to be assessed, I/we authorise the release of information by relevant authorities, including Commonwealth, state/territory or local authorities to the NSW Rural Assistance Authority relating to damage to my business caused by the June 2016 East Coast Storms and Floods and being claimed for in this form.

Signed………………………………………………Signed………………………………………………

Name………………………………………………Name……………………………………………….

Date…………………………………………………Date…………………………………………………

  1. Statements

General Statement

Any person who knowingly and with intent to defraud the NSW Rural Assistance Authority (the Authority) or another person, files an application for assistance containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent act, which is a crime under the Crimes Act 1900 and subjects the person to criminal penalties.

Privacy Statement

The information in this application is provided voluntarily and is being collected by the Authority for purposes related to the administration of the scheme of assistance under which you have applied, including the assessment of the effectiveness of the scheme. This may involve disclosing the information in this application to contractors engaged by the Authority or to either State or Commonwealth government agencies. We will supply you with details of those that we have disclosed information to, if you apply to us in writing. Information regarding your application may also be discussed and exchanged with the nominated contact persons listed by you in your application.

Not providing the information requested in this application or providing false or misleading or incomplete information may impact on the ability of the Authority to accurately assess your application.

The Authority agrees to take all reasonable measures to ensure that the personal information collected by it is stored securely.

You may access or correct your personal information by contacting the Authority by telephone on 1800 678 593 (toll free) or by writing to: Manager Financial Administration, NSW Rural Assistance Authority, Locked Bag 23, ORANGE, NSW, 2800.

Calls to “1800” numbers from your home phone are free. Calls from public phones and mobiles may be timed and attract charges.

Your statement

I/We declare that:

  • the information provided in this form is correct
  • I/we have read and understand the information provided in the ‘Scheme Information and Guidelines’ for this assistance measure
  • the primary production enterprise listed in this application:
  • suffered direct damage as a result of the June 2016 East Coast Storms and Floods, and
  • is an eligible primary production enterprise
  • under normal circumstances more than 51% of our total gross income is derived from the primary production enterprise
  • it is intended that primary production will be re-established
  • I/we have made a claim for insurance where eligible, or insurance has been refused or the payout does not cover all costs, and proof of this claim is attached
  • I/We hereby give approval to the NSW Rural Assistance Authority to obtain and provide information relevant to this application from my/our financial counsellor, accountant or any other nominated person
  • I/we am responsible for the cost of essential repair and/or replacement costs.

I/We understand that:

  • deliberately giving false or misleading information is a serious offence
  • the NSW Rural Assistance Authority can make relevant enquiries to ensure I receive my correct entitlement
  • any overpayment will be recovered
  • personal information is protected and can be given to someone else where state/territory or Commonwealth legislation requires or where I give permission
  • statistics may be collected and analysed in such a way as to protect my anonymity.

Prior to applying for this assistance I/we sought independent financial advice and the taxation implications of any assistance granted has been explained to me.

Signed………………………………………………Signed………………………………………………

Name………………………………………………Name……………………………………………….

Date…………………………………………………Date…………………………………………………

  1. Lodgement of Applications:

Applicants can lodge completed application forms including required documentation with the NSW Rural Assistance Authority by post, email, facsimile or personal delivery at:

Post: Locked Bag 23 (161 Kite Street)

Orange NSW 2800

Email:

Fax: (02) 6391 3098

Telephone:1800 678 593 (Toll Free)

Website:www.raa.nsw.gov.au

Applications must be received by the NSW Rural Assistance Authority no later than 8 May 2017. Applications received after the advertised application period closing date, will not be accepted.

If you have difficulty understanding or completing this form you should seek the assistance of your rural/financial counsellor, business advisor, accountant or a trusted family member/friend.

Language Services (Interpreting and Translating) are available by contacting Multicultural NSW on

1300 651 500 or by visiting

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