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COVID19 – Tenant Rental Payment Assistance Request Form

Home › COVID19 – Tenant Rental Payment Assistance Request Form

COVID19 – Tenant Rental Payment Assistance Request Form

Please complete the following details (1-4 Pages)

Step 1 of 4

25%

Details of Applicant
First Name*
Surname*
Phone*
Email
Address*
Term of the lease:
Outgoings:

Other Tenant/s (if applicable)
Tenant 1 :
Surname
Tenant 2 :
Surname
Tenant 3 :
Surname
Tenant 4 :
Surname

Please complete the following questions
Has your employment been terminated directly related to COVID19?*
- Yes
- No
If no, please indicate the most relevant reason:*
- Shortage of work
- Unsuitability for this type of work
- End of season or contract
- Redundancy
- Misconduct as an employee
- Unsatisfactory work performance
- Employee ceasing work voluntarily
- Other
Have you been laid off on a temporary basis?*
- Yes
- No
Are you entitled to leave entitlements? e.g. sick, long service leave, annual leave*
- Yes
- No
Will you be re-employed once the crisis/lockdown is over?*
- Yes
- No
Have you applied for Income support from the government?*
- Yes
- No
Do you have an insurance policy (such as an income protection policy) which may respond in the circumstances?*
- Yes
- No
Is there anyone else in the household who is still working?*
- Yes
- No
Is there anyone else in the household who will be receiving assistance?*
- Yes
- No
Can you make part payments towards your rent?*
- Yes
- No
Proposed duration:
Start Date
Date Format: MM slash DD slash YYYY
End Date
Date Format: MM slash DD slash YYYY

Details of Rental Assistance Requested
Nominate the type of rental assistance you are requesting*
- Revised Rent Payment Plan
- Rent Rebate (a partial rent refund)
- Break Lease - reduced break lease fee
- Vacate without notice
Please 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
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Declaration
I 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