Emergency Housing Assistance Request

Personal Details

1. 1. * First name
   2. Middle name
   3. * Last name
2. * Date of birth
3. Gender

   • Female
   • Male
   • Indeterminate/Intersex/Unspecified
4. Centrelink Reference Number
5. Contact details
   1. * Mobile
   2. Alternate
6. Email

Other Details

1. * Type of event Please select Cyclone Earthquake Fire Flood Storm
2. Address of affected property

   1. 1. * Unit/Street Number
      2. * Street Name
   2. 1. * Suburb
      2. * Postcode
      3. * State QLD NSW NT VIC SA WA TAS ACT
3. * Affected property is

   • a rental property
   • owned by you or being purchased
4. * How is the property damaged? Please select The property 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
5. *What is your current housing arrangement? Please select Crisis / Refuge Evacuation centre Hotel / Motel Living with family / friends Other arrangement Own property Private rental Social housing
6. Your household
7. * Number of adults
8. * Number of children/dependents under 18 years old
9. Your main income Please select Abstudy Age Pension Austudy Carer Payment Compensation Disability Support Pension Family Tax Benefit JobSeeker Payment Paid Parental Leave Parenting Payment Service Pension Sickness Allowance Special Benefit Superannuation Wages Widow Allowance Widow Pension Wife Pension Youth Allowance
10. Level of home insurance? Please select None Partial Full
11. Level of contents insurance? Please select None Partial Full
12. Has an insurance claim been made?

    • Yes
    • No
13. Additional Comments

• Submit