COVID19 – Tenant Rental Payment Assistance Request Form Please complete the following details (1-4 Pages) Step 1 of 4 25% Details of ApplicantFirst Name*Surname*Phone*Email Address*Term of the lease:Outgoings: Other Tenant/s (if applicable)Tenant 1 :SurnameTenant 2 :SurnameTenant 3 :SurnameTenant 4 :Surname Please complete the following questionsHas your employment been terminated directly related to COVID19?*YesNoIf no, please indicate the most relevant reason:*Shortage of workUnsuitability for this type of workEnd of season or contractRedundancyMisconduct as an employeeUnsatisfactory work performanceEmployee ceasing work voluntarilyOtherHave you been laid off on a temporary basis?*YesNoAre you entitled to leave entitlements? e.g. sick, long service leave, annual leave*YesNoWill you be re-employed once the crisis/lockdown is over?*YesNoHave you applied for Income support from the government?*YesNoDo you have an insurance policy (such as an income protection policy) which may respond in the circumstances?*YesNoIs there anyone else in the household who is still working?*YesNoIs there anyone else in the household who will be receiving assistance?*YesNoCan you make part payments towards your rent?*YesNoProposed duration:Start Date Date Format: MM slash DD slash YYYY End Date Date Format: MM slash DD slash YYYY Details of Rental Assistance RequestedNominate the type of rental assistance you are requesting*Revised Rent Payment PlanRent Rebate (a partial rent refund)Break Lease - reduced break lease feeVacate without noticePlease advise what you propose to the landlord during these circumstances?I apply to (agency name) for rental assistance from my landlord and declare all information provided in respect to this application is true and complete. I have attached the following information: Supporting documents attached Evidence of financial hardship/bankruptcy Proof of reduced hours – Signed letter from Employer on Company letterhead A separation Certificate from my previous employer A statutory declaration stating that I am unemployed and that I am seeking employment. I am self-employed and I have been legally declared bankrupt or my company has been placed into involuntary liquidation Notice to vacate letter from vacating tenants I/We confirm that we are in true financial hardship. I/we have exhausted all options for financial aid and make a declaration that my/our financial position has been adequately portrayed within this application. I/we understand that until such a time that a financial request is negotiated and/or agreed upon, that the rent will remain the same as current, and standard procedures will apply for collection of rent Upload supporting documentUpload supporting documentUpload supporting documentUpload supporting documentDeclarationI hereby declare that the details furnished above are true and correct to the best of my knowledge and belief and I undertake to inform you of any changes therein, immediately. In case any of the above information is found to be false or untrue or misleading or misrepresenting, I am aware that I may be held liable for it. Yes No First Name*Surname*Dated Date Format: MM slash DD slash YYYY