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Application for Home Maintenance Costs Subsidy
(Special Purpose Fund)
Please use this form to apply for a Home Maintenance Subsidy
Personal Details
Persons Name:
*
First name
Last name
Persons Address:
Address line 1
Address line 2
City/Suburb
State/Territory
Postcode
Home phone:
(nnnn nnnn)
enter phone number as nnnn nnnn (no area code required)
Mobile:
(nnnn nnn nnn)
enter mobile number as nnnn nnn nnn
Email address
I wish to apply for a subsidy to assist with the costs of home maintenance
(max. $250.00 per household in any 12 month period)
Note: Applicants will be ineligible for payment of this subsidy if they have income in addition to pensions and benefits and subject to change in criteria from time to time as outlined on the application form)
Amount applied for $:
*
please enter the amount applied for here
Description of maintenance required:
*
Provider details & official quote on provider's letterhead:
*
Please upload official quote from a service provider with an ABN number
Wait..
You confirm you receive a Centrelink Pension & your income does not exceed the average Centrelink Income test for a single person (or couple in the instance of a partnership) as adjusted from time to time.
*
tick box to confirm disclaimer
You have not accessed the Home Maintenance subsidy in the last 12 months (past maximum of $250.
*
tick box to confirm disclaimer
You have exhausted all other available avenues of funding from any external organisation to provide this maintenance for you prior to seeking the subsidy from Beyond Blindness (e.g. NDIS, MAC, Local Council, etc)
*
tick box to confirm disclaimer
Member Signature:
Clear
Verbally Signed:
tick here if verbally signing
Member Signed Date:
*
select date signed
*Beyond Blindness endeavours to assist with member applications in a prompt manner however, please note, the wait time for processing may be approximately 7-10 working days
Financial:
Select this tick box if supplier is to be paid subsidy funds directly from Beyond Blindness (*not to member)
Select this box if MEMBER is to be paid subsidy funds. Note copy of receipt will need to be provided to Beyond Blindness
Member Bank Account Details (only fill out if Member to be paid the subsidy *Not to the supplier)
BSB Number:
enter bank BSB number here (numbers only please)
Bank Account Number:
please enter your bank account number here
Account Name:
please enter your bank account name here
Please check the highlighted fields
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