1. Applicant name*
2. Phone number*
3. Email*
4. Position*
5. Entity name*

   For the purpose of this application entity refers to the Business / Not-for-Profit / Community Group / Sporting Group

6. Entity address*
7. Entity size* Please select... Small business Not-for-profit Community group Sporting club Facility

   Please select the description that best suits your organisation. Please note for the purpose of this application a small business is defined as less than 20 employees and turnover less than $2 million per annum.

8. Entity description*
9. ABN or ACN*
10. Registered for GST? Please select... Yes No
11. Shire of Ashburton rates assessment number or debtor number (if applicable)

Type of assistance sought*

Community / Business support grantRates and special payment arrangementsFees and charges including Shire lessee/licensee rent reliefWrite off outstanding debts incurred since 1 February 2020 as a result of financial hardship and loss due to COVID-19

Select all that apply. Please note this does not guarantee you will receive any / all assistance options.

12. Support grant amount*

    If you are interested in applying for a Community / Business support grant, please indicate the monetary value being requested.

13. Please provide a brief summary of the reason/s for your application.*

    This should include how your organisation has been impacted by COVID-19.

14. Details of steps taken to minimise losses

    List additional support services and funding opportunities the applicant has or intends to pursue.

15. Other financial support*

    Have you applied for or received any other form of financial support and / or grants in relation to COVID-19? If yes, please provide detail.

16. Supporting documentation that details financial hardship and/or loss due to COVID-19*

    Include statement of losses, P&L financials/trading figures, or other financial statements such as BAS, Advice from Accountant or Tax Agent, Bank Statements that show current and enough history to show evidence of change attributed to COVID-19.

17. By submitting this form, I declare that the information contained within is correct and accept that false information supplied will result in a refusal of the financial and/or grant support. I will advise the Shire of Ashburton within five business days should my business circumstances change. The Shire of Ashburton is committed to protecting your privacy. The personal and financial information in the claim form and supporting documentation is being collected by the Shire of Ashburton for the purpose of assessing your application for financial support and relief resulting from the impacts of COVID-19, or any other directly related purpose. The information provided will not be disclosed to any other external party without your consent, unless required or authorised by law. If this information is not collected, we will not be able to fully assess your application or contact you to discuss your application. If you wish to alter any information you have supplied to the Shire of Ashburton, please soa@ashburton.wa.gov.au. I have read and agree to the Terms and Conditions

* denotes a required field.