HARDSHIP UTILITY GRANT SCHEME (HUGS)
Application Form
Fax or email this form, which should be completed and endorsed by a financial counsellor, to
the HUGS Unit immediately after assessment interview with the applicant
Telephone: 9222 2739
Fax: 9221 0178
Applicant’s Utility Account
Email:[email protected]
Account Number
Synergy
Horizon
Water Corporation
Alinta Gas
Busselton Water
Aqwest Bunbury
Name of Account
Note: Please attach copy of utility account to this application
Date of Referral by Utility
Or Disconnected
Expiry Date of Moratorium
Has the applicant been provided with a HUGS
grant(s) within the past 12 months?
If yes, grant amount
Additional Grant
Yes
Yes
No
No
$
Yes
Is this applicant taking advantage of the new initiative for provision of additional grants within
the 12 month period up to 50% of THE NORMAL grant amount?
(By ticking the box you are confirming the applicant has demonstrated genuine
commitment to engage with financial counselling and is not eligible for Exceptional
Circumstances).
Total outstanding amount
$
*
Grant amount applied for
$
*
Applicant contribution
$
*
Other sources of contribution
$
*
(Please provide details below)
* Mandatory Fields
Other Contribution Sources:
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Applicant receiving all relevant rebates prior to HUGS application
Yes
No
Applicant Personal Details
Full Name
Address
Tel No:
Postcode
Regional Development Region
Main Source of Income
Gender
Family Status
Single
Male
Female
Couple
Couple and dependent children
Single and dependent children
Number of children
Age
Housing Tenure
< 18 years
18 – 24 years
25 – 34 years
35 – 44 years
45 – 54 years
55 – 64 years
65 + years
Ethnicity
Aboriginal and Torres Strait Islander (ATSI)
Culturally and Linguistically Diverse (CALD)
English Speaking Background
Reason for Applying for this Grant
Please provide details below
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Owner with mortgage
Owner without mortgage
Private rental
Renter – Public Housing
Renter – Community Housing
Homeless
Other
Exceptional Circumstances
Individual or family home destroyed by fire or storm
Individual or family home broken into with vital personal belongings stolen
Individual or family at risk of imminent homelessness
Individual is a victim of domestic violence
Individual or family experiencing mental health issues
Where marriage/relationship break-up causes a significant decrease in family income
Major unexpected expenses such as medical treatment or funeral costs
A combination of several issues such as loss of income to care for seriously ill family
member
Please provide details below
Authority for Exchange of Information on behalf of the Applicant
I authorise
(name of authorised Financial Counselling Service)
to exchange information on my behalf with Synergy, Horizon Power, Alinta, Water Corporation,
Busselton Water, Aqwest Bunbury, Office of Energy and the Department for Child Protection
HUGS Unit, and the exchange of information between those offices, in respect of my
application for a HUGS grant to assist with payment of my electricity/water/gas acc. ount or for
services received under the Hardship Efficiency Program (HEP).
Applicant’s signature
Date
Referring Financial Counselling Service Details
Financial Counselling Service
Telephone Number
Date of Assessment
Assessed by
HUGS Number
Email Address
Applicant to return for further financial counselling appointments
Financial Counsellor’s signature
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Date
Financial Counsellor’s Recommendation
Based on information provided by client at time of assessment:
Applicant meets the criteria for a HUGS Grant
Amount: $
Applicant does not meet the criteria for a HUGS Grant
Reason:
Nomination for Hardship Efficiency Program ( HEP )
HEP Special Circumstances
HUGS Unit Payment Details
(To be completed by HUGS Unit staff only)
Payment amount
Date payment processed
Payment reference number
Payment not processed
Reason
Endorsed by
(Please print name of HUGS Grant Officer)
Signature
Date
Note: HUGS is a joint initiative between the Office of Energy, Synergy, Horizon Power,
Alinta, Water Corporation, Busselton Water, Aqwest Bunbury, Department for Child Protection,
Financial Counsellors’ Association of Western Australia and Western Australian Council of
Social Service. It is administered by the Department for Child Protection. Information
provided in this application will be kept confidential and used strictly for the purpose of
HUGS and HEP administration only.
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