* Denotes that the field is mandatory.
The City appreciates that everyone’s situation is different and therefore we may ask you questions that may be different and unique to your circumstances to try and maximise our understanding of your situation and this also allows us to confirm that you meet the requirements of the Council Policy so that we are able to offer you, assistance in this current climate.

The City will consider financial hardship relief using the information you provide below as evidence that you have been affected from the COVID-19 State of Emergency.

If you have any queries, please contact the Rates Department on 9477 7222 to discuss prior to completing the application.

Please ensure that you have all the relevant information in the application as this will help with making the process as smooth as possible. Applications should preferably be received before the due date as shown on your rate notice.

Applicant/s Details – All Property Owners must agree to this application
Owner 1 Surname *
First Name *
Residential Address *
Phone *
Perferred Email *
Owner 2 Surname
First Name
Residential Address
Preferred Email
Owner 3 Surname
First Name
Residential Address
Preferred Email
1. Assessment Number *
Rental Property? *
Property Address *
Amount outstanding as per rate notice *
2. Assessment Number
Rental Property?
Property Address
Amount outstanding as per rate notice
3. Assessment Number
Rental Property?
Property Address
Amount outstanding as per rate notice
Do you own property in another Council?
If YES, please attach details below
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This application must be accompanied with evidence of at least one of the below which will show a loss or significant reduction of employment/income:

- A statement of your current financial position from a Financial Advisor

- A letter or email from your Employer advising that you have either been stood down or made redundant and if on Jobkeeper, appropriate letter from your Employer which will need to include your work hours which have been reduced from and to per week approximately

- If you are self-employed or a business, a letter advising how the COVID-19 has impacted your business

- A letter from your Property Manager confirming that your Tenant has lost their employment and you are not receiving any rental income, or a statement of the reduced amount.

- Any other relevant information to help your application

By providing this document/s, the Applicant has authorised the City of Belmont to reproduce this document for internal purposes only.
Attachment 1
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Attachment 2
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Attachment 3
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I understand that the contribution is only for the difference in the annualised residential rate levy from 2019/20 to 2020/21 up to the value of $250.00
If applicable, I wish to apply for assistance through the provision of a Council contribution to my residential rates which has a higher annualised rate in the 2020-2021 financial year.
If you are not already a registered Pensioner / Senior for your Council rates - If you answer yes to any of the next two questions you may be eligible for additional assistance
Are you an owner/occupier of your property and the holder of either a WA Seniors Card or WA Seniors card and a Commonwealth Seniors Health Card (SCHC) or a Pensioner card and receiving a Pension?
Are you currently applying at either Centrelink, Veteran Affairs or Seniors WA for either a Pensioner Concession Card (PCC) or a Seniors Card?
If your application is approved, due to the sensitive information being requested in regard to your bank account details, you will need to complete the relevant Direct Debit application on our website or at the Civic Centre.
Are you currently on a Direct Debit Payment plan with the City?
If No, which payment option would help you on a Direct Debit Arrangement?
How much can you pay each payment?
Commencing on which Friday?
Is there any additional information you would like us to consider?
I / We acknowledge the information provided is true and correct.

I / We acknowledge that a rates staff member from City of Belmont may make contact with me in regard to the application if required prior to it being finalised.

I / We acknowledge that I am obliged to inform the City of Belmont in writing of any changes in my circumstances that would no longer warrant consideration of Financial Hardship.

I / We also acknowledge that by giving the City personal information I consent to it being kept, stored in accordance with the Privacy Act 1988. If I have given someone else’s personal information, I confirm that I have obtained their consent.
Authorisation - Owner 1 *
Authorisation - Owner 2
Authorisation - Owner 3
The personal information collected on this form will only be used by the City of Belmont for the sole purpose of providing requested and related services. Information will be stored securely by the City and will not be disclosed to any third parties without your express written consent.