YOUR NAME:YOUR FILE NUMBER:ARE YOU THE ... - …



3997747-1545200FINANCIAL STATEMENT (COVID-19)YOUR NAME:YOUR FILE NUMBER:ARE YOU THE LANDLORD OR TENANT?:PART A: YOUR FINANCIAL DETAILSDependentsHow many people are in your household? FORMTEXT ?????How has you and your household weekly income been affected by COVID-19Before COVID-19NowYour income after tax$ FORMTEXT ?????$ FORMTEXT ?????Pension or Centrelink payment$ FORMTEXT ?????$ FORMTEXT ?????Financial support you receive for your children/other dependents (e.g. from a former or current partner)$ FORMTEXT ?????$ FORMTEXT ?????Other income (e.g. workers compensation, interest, superannuation payments, rent or board paid to you)$ FORMTEXT ?????$ FORMTEXT ?????Income of other members of your household (after tax)$ FORMTEXT ?????$ FORMTEXT ?????Total income$ FORMTEXT ?????$ FORMTEXT ?????Weekly expenses of your household How much is your cost of living every week?Rent or board$ FORMTEXT ?????Mortgage repayments$ FORMTEXT ?????Credit card and other loan repayments$ FORMTEXT ?????Utilities (e.g. water, gas, electricity, telephone and data)$ FORMTEXT ?????Food$ FORMTEXT ?????Travel and motor vehicle costs$ FORMTEXT ?????Other expenses and health care costs including insurance(attach information about each expense on a separate sheet)$ FORMTEXT ?????Total expenses$ FORMTEXT ?????Assets Things that you own or partly ownHouse and land (market value)$ FORMTEXT ?????Car or other motor vehicle (market value)$ FORMTEXT ?????Other assets (e.g. other property, money owed to you, shares, superannuation or trust funds)$ FORMTEXT ?????Total assets$ FORMTEXT ?????Bank account details Cash: current bank or credit union balances (total for all accounts - provide copies of last statement for each account)$ FORMTEXT ?????Total balances$ FORMTEXT ?????DebtsAmount owing on your mortgage$ FORMTEXT ?????Amount owing on other loans$ FORMTEXT ?????Credit cards total amount owing$ FORMTEXT ?????Other debts (e.g. amount owed to businesses or individuals) Tell us about each debt - attach information about each debt and current loan/credit card statement$ FORMTEXT ?????Total debts$ FORMTEXT ?????PART B: HOW HAS COVID-19 IMPACTED YOU AND HOW MUCH HAS YOUR INCOME REDUCEDDescribe how you are impacted by COVID-19. This information should include whether rent is still being paid, what negotiations you have had with the other party and what the other party has said. Attach additional pages if necessary. FORMTEXT ?????PART C: ACKNOWLEDGEMENTYou must complete this section. Tick if correct: FORMCHECKBOX I have attached copies of documents to support all of the information provided above FORMCHECKBOX I have provided this document and attachments to the other party FORMCHECKBOX I confirm that the above information is true and correct Name FORMTEXT ?????Signature FORMTEXT ?????Date FORMTEXT ????? ................
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