${letterTodayDate}

Application for Financial Hardship

REQUIREMENTS

To apply for hardship assistance please complete the application form below. You must also provide us with the following supporting documents:

•

Proof of income (e.g. last two pay slips, last tax return, Centerlink statements and/or a bank statement)

•

Proof of liabilities/expenses (e.g. rent receipts or mortgage statements, credit or store card, personal loan, car loan statements and/or evidence of any other debts owing)

•

Any default notices that may have been issued

•

Proof of Acceptance of offer made to other creditors

•

Supporting documents specific to the claim (e.g. Medical certificate, employment separation certificate etc.)

APPLICANT/S DETAILS

Applicant 1

Account Number: ${originalAccountNumber}

Surname: ${lastName}

Given Name(s): ${firstName}

Date of Birth: ${dateOfBirth}

Residential Status: ${hshipResident}

Number of dependants: ${hshipDependents}

Reason for hardship: ${hshipReason}

FINANCIAL POSITION

Applicant 1

Will you be able to maintain yout monthly payments going forward? ${hshipMaintain}

Employment Status: ${hshipEmployment}

Have you applied for financial hardship with any other companies? ${hshipOthHardship}

Will this situation improve within 3 months?: ${hshipChange}

Why do you think your situation will or will not change in the next 3 months? ${hshipChangeWhy}

How much can you afford to pay? $${hshipAffordPay} ${hshipPayFreq}

ASSETS - WHAT YOU OWN

Home / Properties

Assets

Present Value

Home

$${asshome}

Other Real Estate

$${assOthRealEstate}

Home Contents

$${assHomeContent}

Motor Vehicles

$${assRegNum}

Savings

$${assCashBank}

Other Assets

$${assOther}

Income

Income Type

Monthly

Income

$${mthIncNetPay}

Partners Income

$${mthIncPtnrNetPay}

Centrelink

$${mthIncCentrelink}

Total Other Income (i.e. dividends, interests, or rental income)

$${mthIncOtherInc}

LIABILITIES - WHAT YOU OWE

Monthly Expenditure

Type of Expenditure

Total Value

Home Loan/s

$${liaCarLoan}

Personal Loan/s

$${liaPerLoan}

Credit / Stores Cards/s

$${liaCreditCard}

Other Loan/s

$${liaOthLiability}

Other Liabilities

Types of Monthly Expenditure

Monthly

Rent / Mortgage repayments

$${expMortgage}

Insurance

$${expHmConInsur}

School Fees

$${expSchoolFee}

Electricty

$${expElectricity}

Gas

$${expGas}

Medical Expenses

$${expCarInsur}

Rates (Council / Water)

$${expRates}

Car / Travel

$${expTravel}

Clothing

$${expClothing}

Entertainment

$${expEntertain}

Other

$${expOtherExp}

DECLARATION AND AUTHORITY

I/we have read and understood the particulars of this application. All particulars declared in this application are true, complete andcorrect and have been provided to Lombard Pty Limited (‘Lombard Finance’) to assess my/our application for Hardship assistance.

I/we acknowledge that if I/we have made an untrue representation or statement to obtain Hardship assistance, the application will be deemed ineligible for such assistance. Any application found to be in this position during the assistance period will result in the termination of this assistance and the credit contract will be managed in accordance with Lombard Finance’s collections policy.

I/we acknowledge and consent to the matters in the Privacy Disclosure and Consent Statement. I/we understand and agree that a credit check may be undertaken as part of this application. I/we also acknowledge and agree that Lombard Finance may contact a third party, such as your employer, accountant, solicitor, financial representative or other referee/s to verify the accuracy of the information provided.

I/ we declare that where I/we have provided personal information about any other person (such as a referee, employer, solicitor, financial representative or other contact), I/ we agree to immediately advise them:

•

That I/we have provided this information to Lombard Finance;

•

The reason I/we have provided this information;

•

Lombard Finance’s contact details;

•

That they can gain access to their personal information by contacting Lombard Finance; and

•

That Lombard Finance collect, use and disclose personal information pursuant to the Privacy Disclosure and Consent Statement.
Credit provided by Lombard Finance Pty Ltd ABN 31 099 651 877, Australian Credit Licence number 247415 (Lombard). Lombard® is a trademark of Lombard. Lombard is a subsidiary of FlexiGroup Limited.