Application For Housing Assistance Form Page 6
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1918. Do you make regular child
Yes
No
Go to 19.
support payments?
give details
Attach proof. See item 10 on
How often do
How much do you
the Evidence Requirements
How do you pay?
you pay?
pay?
Information Sheet for details.
Through a government agency
$
Directly to the person
Through a government agency
$
Directly to the person
19. Do you have ongoing expenses
Yes
No
Go to 20.
due to a disability, medical
give details
condition or permanent injury?
How often do
How much do you
What is it for?
Attach proof. See item 11 on the
you pay?
pay? (approximately)
Evidence Requirements
Information Sheet for details.
$
$
$
$
Your household
20. Will there be other people living with
Yes
No
Go to 20a.
you?
write the number of
people who will be
Note: If there will be other people living with
living with you
you, please include their details in the
(including an
Additional Person Information section of this
expected baby)
form when you get to it. For an expected
baby, you only need to provide the details in
question 20a.
20a. Is anyone on this application
Yes
No
Go to 21.
expecting a baby?
give the due date
Attach documents that support your answer.
DD/MM/YYYY
See item 12 on the Evidence Requirements
Information Sheet for details.
21. Is anyone on this
Yes
No
Go to 22.
application an
give details
employee of a social
Name of person
Family Name
First Name
housing provider?
Note: This includes all
employees of FACS
Name of social
or community housing
housing provider
providers in NSW.
DH3001 04/15
Page 4 of 16
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