Financial Assistance Scheme for Attach

receipts
here
Uncontracted Assessors
Application Form - Individuals

Please use this form to lodge an application under the Financial Assistance Scheme if you are an individual who did not
have a Green Loans contract directly with the Department. An individual includes a sole trader operating under a
registered business name. Do not use this form if you are a company claiming in respect of employees/contractors. The
Organisations Application Form can be found at
http://www.climatechange.gov.au/en/government/programs-and-rebates/green-loans/financial-assistance.aspx
Eligibility requirements for the Scheme are contained in the Financial Assistance Scheme Guidelines, which also define
the key terms used in this application form. You should read the Guidelines prior to completing this application form. The
Guidelines and more information can be found at
http://www.climatechange.gov.au/en/government/programs-and-rebates/green-loans/financial-assistance.aspx
An applicant may submit one application only for the Scheme. Subsequent applications from the same Applicant will not
be considered.
Applicants should refer to section 15(1) of the Scheme Guidelines regarding taxation implications prior to completing this
form.

Lodgement
Your application must be received by the Department on or before Monday 2 May 2011. After this date, your
Financial Assistance Scheme Application Form will not be accepted. The Department will not accept emailed, faxed or
scanned applications.
Your completed application form and all supporting documentation should be sent to:
Financial Assistance Scheme
GPO Box 9923
Perth WA 6001
Please keep a copy of your application form and all supporting documentation for your records as this information will not
be returned to you.

1. Your details
Title Mr Mrs Miss Ms Other
First name

Last name

Registered business
name/trading name (if any)
Previous name* (if name has
changed since ABSA
accreditation)

HO Number (if you have been

accredited by ABSA)

Residential address

Suburb/town State Postcode

Postal address
(write ‘as above’ if the same as
Residential address)

Suburb/town State Postcode

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* Where the name on the receipts provided is different to the name on this application due to a change of name, you must
provide evidence that verifies that you incurred the costs under the name identified in the receipts (e.g. marriage
certificate).
I have attached evidence of change of name Not applicable

2. Contact details
Please provide your contact details below. Providing us with a telephone number and e-mail address means that
we can contact you during business hours should we have any questions and may assist us in processing your
claim. Not being able to contact you may mean that your application will be assessed on the available information
only.
Daytime telephone number ( )
(include area code)
Mobile number

E-mail address

3. Eligible costs incurred

Only eligible costs supported by the required evidence may result in an assistance payment. Evidence must be
attached to this Application Form. Please refer to section 5 of the Scheme Guidelines for further details.
Please ensure all receipts attached are original or a clear and readable certified copy. Receipts will not be
returned. Receipts must be in the same name as the applicant (unless evidence of a name change can be
provided) and must include the following details:
• the name of the issuer;
• the service to which the payment relates;
• the amount paid; and
• the date paid.

Application details
Please tick and complete the appropriate items below:
Tick Eligible cost Amount paid $ (GST Total amount Receipt attached
(if applicable) inclusive) claimed $ (GST (please tick)
inclusive)

HSA Training fee $ $ Yes No

Insurance premium $ $ Yes No

ABSA fee $ $ Yes No

Police check $ $ Yes No

Note: The amount claimed for each Eligible Cost item must be reduced by the amount that you have received, or
are entitled to receive, from any source by way of a reimbursement, subsidy or refund for all or part of any of the
costs referred to in section 5(1) of the Scheme Guidelines.

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4. Photo identification
Please attach a clear and readable certified copy of one of the following forms of photographic identification.
Please tick the appropriate box below for which a certified copy is attached:

Current photo driver’s licence or permit

issued by a State or Territory government

Photo ID proof of age card issued by a State

or Territory government

Current passport (or expired within last

2 years) issued by the Commonwealth; or

Current ABSA identification.

5. Bank account details

Your financial assistance payment can only be paid directly to your personal Australian bank account (i.e. the
nominated account must be held in your name).

Name of account holder(s)

Name of financial institution

BSB number

Account number

Required documentation* (If applicable)

Receipt from training provider

Receipt from insurance provider

ABSA accreditation receipt

Police check receipt

One type of Photo Identification

Proof of change of name**

* Originals or clear and readable certified copies are required. Please keep a copy of all supporting documentation
for your records as this information will not be returned to you.
** Where the name of the receipts provided is different to the name on this application due to a change of name,
you must provide evidence that verifies that you incurred the costs under the name identified in the receipts
(e.g. marriage certificate).

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6. Declaration, acknowledgement and release
I declare that:
• all information provided on this form, including attachments, is true and correct.
• all receipt(s) attached include eligible costs as listed on this form and in the Scheme Guidelines.
• the receipt(s) are not the subject of any other current claim to the Department of Climate Change and
Energy Efficiency.
• the amount claimed for each item has been reduced by the amount that I have received, or am entitled to
receive, from any source by way of a reimbursement, subsidy or refund.
• I have read and understand the Scheme Guidelines.
I consent to the Department using and disclosing information about my claim, including this application, in
accordance with the privacy notice on this form.
I understand and acknowledge that:
• providing false and misleading information is an offence under the Criminal Code Act 1995
• the Commonwealth may recover from me, as a debt due and payable to it, the financial assistance that it
pays to me under the Scheme if:
- I provide false or misleading information; or
- the Department otherwise determines that I am not entitled to the assistance in accordance with
the Scheme Guidelines.
Release and undertaking
Contingent upon my receiving payment under the Scheme, I hereby release the Commonwealth from any legal
liability to me in respect of any claimed costs or losses arising from my being an Uncontracted Assessor and in
relation to the Green Loans Program.
I undertake not to make any other kind of claim or application for compensation or other payment in respect of
claimed costs or losses arising from my being an Uncontracted Assessor and in relation to the Green Loans
Program.

Printed name

Signature
Date

Privacy Notice

The information on this form (including attachments) and any other information or documents generated as a result of your application will be used to
assess your eligibility to receive a payment under the Financial Assistance Scheme. That information may be used and disclosed for those purposes
by the Department of Climate Change and Energy Efficiency or a delivery agency that it engages. The information may be disclosed for those
purposes outside of the Department or delivery agency to contracted advisors, other Commonwealth, State or Territory government agencies, training
organisations, insurance companies, the Australian Federal Police and any other third party that may assist to verify the claim and ensure compliance
with the Scheme Guidelines. Your financial institution account details will be used to facilitate payment of your claim.

The Department and delivery agency may also use and disclose the abovementioned information for any other governmental purpose including
reporting on the Financial Assistance Scheme, or for related research and policy development purposes. Application, claim and payment information
may also be disclosed to the Australian Taxation Office for compliance purposes and to the Australian Federal Police in the event of suspected fraud.

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