Lot Owner Name *

First Name

Last Name

Lot Owner Phone Number *

(###)

###

####

Property Use: *

Your principal place of residence

Rental/investment property

Secondary residence/holiday home

Are you able to make any payment at this present time? *

Yes

No

Are you requesting: *

A short-term extention (to be paid within 3 months)

A payment plan

Proposed Instalment Frequency *

Weekly

Fortnightly

Monthly

Date of First Instalment *

MM

DD

YYYY

Date of Last Instalment *

Note: This cannot exceed a 12-month period from the start date.

MM

DD

YYYY

*

I confirm that any levies issued after the potential approval of this financial hardship application will be paid by its relevant due date, or this application will be revoked.