Application For Assistance Form - Njamal People's Trust

SECTION A: Type of Assistance

Tick ONE BOX ONLY below to select the type of assistance your require:
(if you need to apply for more than one type of assistance please fill out a separate application form each)

Type of Assistance*

SECTION B: Personal Details

First Name:*

Last Name:*

D.O.B:*

DD

MM

YYYY

Email:

Phone:*

Address:*

Street Address Address Line 2 Suburb State / Province / Region Postcode

ATTENTION: If your application is relating to Hardship and OPF please proceed to Section G, H & I.

SECTION C: Application for a child

Please provide the following information:

Child's Full Name	DOB	Year/Class	Address of the Child

SECTION D: Medical Assistance

Please provide the following information & documents for assistance relating to Medical:

A letter from the medical professional or social support worker

Letter from the medical professional or social support worker

Date of the appointment:

DD

MM

YYYY

SECTION E: Carer's Assistance

Please provide the following information & documents for assistance relating to Carer:

A letter from the medical professional / social support worker

Letter from the medical professional / social support worker

Carer's Assistance

Appointment Date	Name of the Patient	Relationship to the Patient

SECTION F: Sports Assistance

Please provide the following documents for assistance relating to Sports:

Completed registration of the sports event, lessons or course

Completed registration form

Please provide the following documents for assistance relating to Sports:

A support letter from the sports institution

Support letter from the sports institution

SECTION G: Funeral Expense Assistance

Funeral Notice

Funeral Date

DD

MM

YYYY

SECTION H: Expenses Requested

Expenses Requested*

What is the money for?	Who is being paid?	Requested Amount

SECTION I: Why do you need help?

(What has happened recently that has caused you to ask for help?)

SECTION J: Declaration

*

I declare that the above information is true.

Signature*