Relief and Welfare Fund Application for Assistance

Your details

Name *

Rank/position

FRNSW service / payroll number *

Station number or department *

Mobile phone number

Work phone number

Email (preferred work or personal) *

Preferred communication method *

EmailPhoneSMS

Address *

Street address *Street address line 2

City *

State *

Postcode *

Current situation

Current situation (demonstrating financial hardship) *

Income

For incomes below that are nil, please place $0 in the field.

Personal income per fortnight *

Family Tax Benefit per fortnight

Other Centrelink benefits per fortnight

Child support per fortnight

Rental income per fortnight

Other investment incomes per fortnight

Other income types

Income per fortnight

Expenses

For expenses below that are nil, please place $0 in the field.

Mortgage payments per fortnight

Rental payments per fortnight

Child support payments

Vehicle payments

Vehicle expenses

Rates

Household expenses

Groceries

Electricity/Gas

Medical/Dental

Phone/Internet

HECs payment

Credit card payments

Loan repayments

Insurances

Child-care/Pre-School/School fees

Other expense types

Expense per fortnight

I confirm that the information provided in this statement is true and correct to the best of my knowledge. I understand that any false information made in this statement may lead to my claim being denied and additional action may be taken. *