Apply for Assistance - POP Foundation, Rural & Regional Families Support

Applicants Details

For any fields that do not apply, please mark N/A for not applicable.
Full Name*
Date of Birth*
Residential Address*
Telephone*
Email*
Occupation
Length of Employment
Reason for Unemployment*

*If currently unemployed please state previous job/ how long have you been unemployed for? Enter N/A if not applicable.
Housing Situation*
- Own Home outright
- Own home with Mortgage
- Renting
- Other
Other:
Marital Status*
- Married
- Single
- Sole Parent
- Widowed
- De-facto Partnership
- Separated
Are you an Australian Citizen?*
- Yes
- No
What is your country of citizenship?
Are you of Aboriginal or Torres Strait Islander origin?*
- Yes
- No

Spouse/Partner Details
Full Name
Date of Birth
Residential Address
Telephone
Length of Partnership
Occupation
Length of Employment
Reason for Unemployment

*If currently unemployed please state previous job/ how long have you been unemployed for? Enter N/A for not applicable.

Dependents (Under 18 years of age)
Do you have any Dependents?
- Yes
- No
Dependents
Name Relationship DOB Year Level at School
Family Circumstances - Short Description

(Please describe the circumstances leading to this Benevolence assistance application)
Family Circumstances Description*
Details of Assistance Requested
Please indicate below the expenses for which you are requesting assistance
Item/Service/Bill Date needed Cost ($)
Comments

Financial Detail
Household Monthly Income

Total Income (Salary, centrelink/pension, Business Income etc.)
Applicant
Partner
Bank Interest/ Investment Income
Applicant
Partner
Other
Applicant
Partner
Financial Details continue -
Combined Household Monthly Expenses
Mortgage Repayments
Rent
Rates including Water
House and/or Contents Insurance
Vehicle Expense (fuel, Insurance, Registration & Maintenance)
Food Expenses
Telephone/ Internet (Home and Mobile)
Electricity/Gas Expenses
Private Health Insurance Expenses
Essential Travel Expenses (Go card, Bus tickets etc.)
Medical/Hospital Expenses
Credit card (minimum monthly repayment)
Loan Repayments (excluding credit card payments)
Dependent Expenses (School Costs etc.)
Other (Life Insurance, Super payments, Memberships etc.)
Total Expenses
Assets – (Items of Value) - Property
Address Value
Other Assets – Car, Boat, Caravan, Farm Assets, Business Assets
Type Value
Savings/ Investments
Type Value
Liabilities – (Money owed to other Organisations or People) Mortgages
Date Commenced Organisation/ Person Initial Amount Borrowed Amount Owing
Other Commitments (credit Cards, Centrelink Advance/Loans, Overdrafts, Personal Loans, Overdue Accounts, Hire Purchases, Privately borrowed money)
Date Commenced Organisation/ Person Initial Amount Borrowed Amount Owing
Have any other funding bodies/charities been engaged/approached for assistance?
- Yes
- No
If yes, please provide details and outcomes
Can any of these items be funded through government funding?
- Yes
- No

Protecting your Privacy

All information provided by you will be treated in accordance with our Privacy Policy and our obligations under the Privacy Act 1988 (COM), Information Privacy Act 2009 (QLD) and the Australian Privacy Principles (APP)
*
- * I give consent to POP Foundation to collect and record my personal details including information about my health and financial situation for the purpose of providing me or someone else I know with a service. This information will only be used for internal assessment and processing purposes.
Declaration

I/We declare that have read and agree to POP Foundations privacy guidelines. I/We understand that if I/We do not provide all the information requested, that I/We might not be eligible to receive assistance from POP Foundation. I/We certify that the information provided on this application is true and correct. I/We understand that withholding information or providing false information may result in POP Foundations refusal of this application. If an application containing false or misleading information is accepted by POP Foundation and support is provided I/We may be legally required to reimburse POP Foundation up to the amount they provided.

Applicant
Full Name*
Date*
DD slash MM slash YYYY
Signature 1*
- * (required) By typing my full name and date above, I agree that all of the information provided in this application is true and correct.
Spouse/Partner
Full Name*
Date*
DD slash MM slash YYYY
Signature 2*
- * (required) By typing my full name and date above, I agree that all of the information provided in this application is true and correct.
Terms and Conditions

All applications for charitable assistance are to be made on the appropriate form (Application for Benevolence Assistance form) provided by POP Foundation. Each Application needs to be signed by the Applicant and Spouse/Partner.

Further Documentation and evidence may be requested by POP Foundation at any staged if need be.

Each Application is assessed by POP Foundations assessment panel, who will make decisions around what assistance (if any) can be provided.

Each Application is assessed on a case-by-case basis. POP Foundation reserves the right to reject claims without explanation. Each assessment decision is final and non – negotiable.
Where did you hear about POP Foundation?
Other*
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Application Assistance Forms

Apply Online or Download Assistance Forms

Apply Online

Applicants Details

Spouse/Partner Details

Dependents (Under 18 years of age)

Family Circumstances - Short Description

Details of Assistance Requested

Financial Detail
Household Monthly Income

Financial Details continue -
Combined Household Monthly Expenses

Protecting your Privacy

Declaration

Applicant

Spouse/Partner

Terms and Conditions

Name	Relationship	DOB	Year Level at School

Item/Service/Bill	Date needed	Cost ($)

Address	Value

Type	Value

Application Assistance Forms

Apply Online or Download Assistance Forms

Apply Online

Applicants Details

Spouse/Partner Details

Dependents (Under 18 years of age)

Family Circumstances - Short Description

Details of Assistance Requested

Financial Detail Household Monthly Income

Financial Details continue - Combined Household Monthly Expenses

Protecting your Privacy

Declaration

Applicant

Spouse/Partner

Terms and Conditions

Financial Detail
Household Monthly Income

Financial Details continue -
Combined Household Monthly Expenses