Maitland Region Community Support: Enquiry Form

PERSONAL INFORMATION

First Name *

Last Name *

Primary Contact (Phone number or E-mail address): *

Suburb: *

Aboriginal

Torres Strait Islander

Country of Birth *

WHAT ARE YOU SEEKING ASSISTANCE FOR (select all that apply):

EAPA (Electricity / gas assistance)

NILS (No Interest Loan)

Other

MORE INFORMATION

Do you currently have a NILS Loan? *

YesNo

Have you ever had a NILS loan before? *

YesNo

Is your individual income under $70,000 before tax? *

YesNo

Unfortunately you are not eligible at this time to receive a NILS loan. If you require any other assistance, please contact MRCS on 4932 0950.

What is the purpose of the loan? *

Whitegoods (e.g. fridge / freezer)Household furniture (e.g. living / dining)Health and wellbeing (e.g. dental / psychology)Unexpected vet billEducation / Employment (e.g. essential technology / certification)Car registration / repairs (current registration papers in your name must be provided)

What is the total cost of the loan (up to $2000 total)? *

How long have you lived in your current address? *NB: NILS are assessed on a case by case basis *

0 - 3 months3 - 6 months6+ months

FABULOUS! You may be eligible for a NILS loan.

In order for us to move forward with your loan application, please ensure you have all of the following:

*please note: proof of identity must include a minimum of two documents

Information required *

Proof of identity (e.g. Australian driver's license, proof of age card, Centrelink card, Australian passport, birth certificate)Proof of address (e.g. rental agreement, mortgage statement, statutory declaration)Proof of income (e.g. payslip, current Centrelink statement, bank statement)Proof of any current money owing (e.g. Afterpay statement, credit card statement)Quotes (e.g. invoice for the goods needing purchase - including company's ABN and payment details)

Date of birth: *

Contact email address: *

Residential address (including suburb) *

Once we receive your enquiry, we will contact you using the details listed above within three business days to arrange an appointment to come in.

Please note, we may require additional information at your appointment (e.g. bank transactions / payment confirmation), so please allow a reasonable time for the appointment.

Please specify what you require assistance for: *

Thank you for your enquiry. We will find the appropriate team member and get back to you within three business days. If your enquiry is urgent, please contact MRCS directly on 4932 0950.

Is the bill for your current address? *

YesNo

Is the bill in your name? *

YesNo

Unfortunately you are not eligible for EAPA. If you require any other assistance, please contact MRCS on 4932 0950.

To assist with EAPA, we require an appointment the the person that is named on the account (or an authority on the account). Please contact us on 4932 0950 or contact your energy provider to be added to the account.

When is the bill due? *

What is the bill for? *

ElectricityGasWater

Who is the energy provider? *

What is the amount owing for the current bill? *

FABULOUS! You may be eligible for EAPA.

In order for us to move forward with an appointment, please ensure you have all of the following:

*please note: proof of identity must include a minimum of two documents

Information for EAPA: *

Full copy of the current billProof of identity (e.g. Australian driver's license, proof of age card, Centrelink card, Australian passport, birth certificate)Proof of income (e.g. payslip, current Centrelink statement, bank statement)

Once we receive your enquiry, we will contact you using the details listed above within three business days to arrange an appointment to come in.

Please note, we may require additional information at your appointment, so please allow a reasonable time.

Comments:

All information is kept by Maitland Region Community Support on a secure online database and remains confidential. Basic information is used for reporting purposes.