Emergency housing assistance request form

Personal Details

1. 1. First name *
   2. Last name *
2. Date of birth *
3. Contact phone number
   1. Main *
   2. Alternate
4. Email address
5. Your address
   1. Suburb *
   2. Postcode *
   3. Unit/Level/St No *
   4. Street Name *
6. Your main income Please select Abstudy Age Pension Austudy Carer Payment Casual Earnings Commission Compensation Disability Support Pension Family Tax Benefit Part A Newstart Allowance Paid Parental Leave Parenting Payment Partnered Parenting Payment Single Self Employed Service Pension Sickness Allowance Special Benefit Superannuation Wages War Widows Pension Widow Allowance Widows Pension Wife Pension Age Wife Pension Disability Youth Allowance

Other Details

1. Type of event * Please select Flood Storm Cyclone Fire Earthquake
2. Who is in your household?
   1. Number of Adults *
   2. Number of children/dependents under 18 years old *
3. What are your current housing arrangements? * Please select Own property - remained in affected property Private Rental property - remained in effected property Private Rental - moved to property following incident Evac Centre Hotel / Motel Crisis / Refuge Living with family / friends Social Housing - remained in affected Social Housing - moved to property following incident Other Arrangements
4. Is your usual home *
   • owned by you or being purchased?
   • a private rental property?
   • None
5. Is your home insured?
   • Yes
   • No
   • N/A
6. Are your contents insured?
   • Yes
   • No
   • N/A
7. Has an insurance claim been made?
   • Yes
   • No
   • N/A
8. How is your property damaged?
   1. Damage * Please select Your home is not damaged but there is some damage to the yard, sheds, fences, trees down etc Minor damage e.g. some broken windows, minor roof damage, trees uprooted, flooded yard but not home Moderate e.g. many broken windows, roof/wall damage, kitchen/bathroom unusable, minor indoor flooding Major e.g. part of roof lost, holes in exterior walls, major tree damage to home, flooding inside Destroyed e.g. loss of roof, collapse of some or all exterior walls, complete inundation by flooding
   2. Additional Comments

• Submit