Mortgage Relief Application Form Page 2
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2
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61
2
APPLICANT
APPLICANT
Mr
Mrs
Ms
Miss
Mr
Mrs
Ms
Miss
Family name
Given name(s)
Date of birth
Age
Date of birth
Age
Driver’s license no
Occupation
Language spoken at home
Is an interpreter required?
yes
no
yes
no
Country of birth
Country of birth
If there are more than two owners of the property, please attach a separate sheet with above details
INCOME AND EMPLOYMENT DETAILS
1
2
APPLICANT
APPLICANT
Current/last employer
Contact name
Phone number
from
to
from
to
Period of employment
Period of employment
per
$
per
$
Gross salary/wages
Gross salary/wages
Net salary
(less tax only)
per
$
per
Net salary
$
(less tax only)
If you are employed, you must provide a statement from your Employer confirming your total gross
earnings for the past 13 weeks (including overtime) and two recent pay slips.
If you are Self-Employed, you must provide a Profit and Loss Statement for the past 13 weeks prepared
and signed by a Certified Practicing Accountant .
If you are receiving a benefit from Centrelink, Transport Accident Commission, Workcover or another
Statutory Body you must provide a current income statement from the relevant Government organisation.
yes
no
Are you currently in receipt of any benefits?
per
$
from
Type of benefit
$
per
Additional family payments or benefits
Other family members in dwelling (adults & children)
Ages
OTHER SOURCES OF FAMILY INCOME
Income of other family members living in house (including Centre Link benefits and pensions)
$
Name
Income
per
$
per
Board
$
Other
per
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