form test page - Elevant

This field is for validation purposes and should be left unchanged.

1. Applicant Details

First Name*

Last Name*

Phone*

Date of Birth*

Email*

Address

Loan Account Number*

2. Reason for Hardship

What is the reason for hardship?*

Please provide the reason for the request and the support you require*

3. Financial Position

Monthly Income:

Employment income (after tax)*

Government benefits*

Other income*

Total income

Monthly Expenses:

Rent / Mortgage*

Utilities (electricity, gas, water)*

Food & groceries*

Transport

Insurances*

Other essential expenses*

Total Expenses

Other Debts (if applicable):

Lender / Creditor

Balance Owing

Repayment Amount

Repayment Frequency

Lender / Creditor Balance Owing Repayment Amount Repayment Frequency

4. Proposed Arrangement

Reduce repayments

Reduce repayments details

From $ Per

To $ Per

Payment pause

Deferral of repayments for Months / weeks

Recommencing on Date

Other

Other reason

5. Attach Supporting Documents

Recent payslips (at least 3) / Centrelink statements

Max. file size: 50 MB.

Bank statements (at least 6 months)

Max. file size: 50 MB.

Medical certificates (if applicable)

Max. file size: 50 MB.

Bills or other supporting evidence

Max. file size: 50 MB.

6. Declaration:

I declare that the information provided in this form is true and correct to the best of my

Signature Date*

How can we help?*

What would you like to reduce your instalments to?*

Expected duration of hardship*

Please provide the reason for the request and the support you require*

By signing this form, you agree that you’ve read the Hardship T&Cs

Hardship T&Cs*

I agree I have read the Hardship T&Cs

Signature