CLAIM FOR NATURAL DISASTER
TRANSPORT SUBSIDY
June 2016 Tasmanian Floods
Submit all claim forms with copies of tax invoices.
Initial claims MUST be submitted by 30 November 2016.
CHECKLIST
To avoid any delay in the processing of your claim, please complete the following checklist.
Have you attached the required documents with this claim?
Proof of property location (Copy of latest Local Government Area (LGA) rates notices)
Proof of Expenditure (Tax Invoices)
Owner Carrier (Copy of Registration Papers)
Did you answer all the questions and include the following information?
Business ABN number
Bank account details
Did you sign and date the consent (page 4), and statement (page 5)?
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Have you applied previously for assistance from AgriGrowth Tasmania?
YES
NO
(Please tick either ‘Yes’ or ‘No’)
1. ABOUT YOU
Applicant(s) Full Name(s) :
Full Property Address:
Postcode:
Local Government Area
(LGA) of property:
Please attach copy of latest LGA rates notices
Postal Address:
(If different to property address)
Phone:
Mobile:
Fax:
E-mail:
2. ABOUT YOUR PRIMARY PRODUCTION ENTERPRISE
Trading name if different from
the legal / registered name:
ABN:
Main industry of enterprise:
(please circle)
ACN:
Meat & Wool | Dairy | Intensive Animal Production | Horticulture
Perennial Horticulture | Grains
| Cropping | Private Forest | Aquaculture
Other:
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3. REASON FOR CLAIMING
Has this business suffered direct damage as a result of the June 2016 Tasmanian floods?
Is this claim for:
(please tick)
YES
NO
Road transport of stock from a disaster affected area to areas of agistment YES
NO
Road transport of stock from agistment to a previous disaster affected area YES
NO
Road transport of fodder to a disaster affected area YES
NO
Road transport of water to a disaster affected area YES
NO
Road transport of stock to sale or slaughter YES
NO
Road transport of building materials directly associated with primary YES
production, fencing materials, machinery or equipment
NO
NOTE: Initial claims must be submitted no more than 6 months after the first movement with the first movement to
take place within the first 3 months of a Natural Disaster declaration.
Subsidy Amount
($)
Subsidy (%)
OFFICE ONLY
Cost per kilometre
Distance Carried (kms)
Carried to
Carried from
Amount paid to
Carrier
Carrier’s Name
Number / Weight /
Litres
Movement Type (e.g.
stock / fodder / water /
materials)
Date Loaded
Movement Number
Particulars of Transportation movements and costs
1
2
3
4
5
•Please attach copies of all tax invoices.
•If owner carrier please supply copy of vehicle registration papers.
•Please provide evidence of purchase (fodder/water/materials) and/or confirmation of agistment.
•If insufficient room for details of all transportation costs/movements, please list details on separate sheet(s), and attach
with this form.
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Particulars of stock and fodder on hand
Number of stock on hand: Sheep/Goats/Deer
Dairy Cattle
Beef Cattle
Fodder on hand prior to arrival of fodder referred to on this form (nearest tonne):
Hay
Grains
Other
4. BANK ACCOUNT DETAILS
Please provide bank account details for payment of grant
Account Name:
Bank/Credit Union etc Name:
BSB:
Account No:
5. CONSENT FOR RELEASE OF INFORMATION
I/We have lodged a claim with AgriGrowth Tasmania for a transport subsidy in relation to the June 2016 Tasmanian
floods.
To allow this claim to be assessed, I/we authorise the release of information by relevant authorities, including
Commonwealth, State or local authorities to AgriGrowth Tasmania relating to the 2016 Tasmanian floods and being
claimed for in this form.
Signed
Signed
Name
Name
Date
/
/
Date
/
/
6. STATEMENTS
General Statement
Any person who knowingly and with intent to defraud AgriGrowth Tasmania or another person, files an application for
assistance containing any materially false information, or conceals for the purpose of misleading information concerning
any fact material thereto, commits a fraudulent act, which may subject the person to criminal penalties.
Privacy Statement
The information in this application is provided voluntarily and is being collected by AgriGrowth Tasmania for purposes
related to the administration of the scheme of assistance under which you have applied, including the assessment of the
effectiveness of the scheme. This may involve disclosing the information in this application to contractors engaged by
AgriGrowth Tasmania or to either State or Commonwealth government agencies. We will supply you with details of
those that we have disclosed information to, if you apply to us in writing. Information regarding your application may also
be discussed and exchanged with the nominated contact persons listed by you in your application.
Not providing the information requested in this application or providing false or misleading or incomplete information
may impact on the ability of AgriGrowth Tasmania to accurately assess your application.
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AgriGrowth Tasmania agrees to take all reasonable measures to ensure that the personal information collected by it is
stored securely.
You may access or correct your personal information by contacting AgriGrowth Tasmania by telephone on 03 6777 2233
or by email to [email protected].
Your statement
I/We declare that:
• the information provided in this form is correct
• the primary production enterprise listed above:
•suffered direct damage as a result of a declared Natural Disaster, and
•is an eligible primary production enterprise
I/We understand that:
• deliberately giving false or misleading information is a serious offence
• AgriGrowth Tasmania can make relevant enquiries to ensure I/we receive my correct entitlement
• any overpayment will be recovered
• personal information is protected and can be given to someone else where State/Territory or Commonwealth
legislation requires or where I/we give permission
• statistics may be collected and analysed in such a way as to protect my/our anonymity.
Prior to applying for this assistance I/we sought independent financial advice and the taxation implications of any
assistance granted has been explained to me/us.
Signed
Signed
Name
Name
Date
/
/
Date
/
/
8. LODGEMENT OF APPLICATIONS:
Applicants can lodge completed application forms including required documentation to AgriGrowth Tasmania by email to:
[email protected]
Post to: AgriGrowth Tasmania, PO Box 46, Kings Meadows, TAS 7249
Fax: 03 6344 9814
Applications must be received by AgriGrowth Tasmania no later than the closing date, 30 November 2016.
Applications received after the application period closing date in any other circumstances will not be accepted.
Contact details:
Telephone 03 6777 2233
Email: [email protected]
If you have difficulty understanding this form you should seek the assistance of your rural/financial counsellor, accountant
or a trusted family member/friend.
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