IRISH SUPPORT AGENCY NSWFinancial Assessment form Name * First Name Last Name Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Date of birth MM DD YYYY Visa Type Your Partner's Information First Name Last Name Email Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Date of birth MM DD YYYY Visa Type PPS Number Additional Family Members in Household If you have more than 2 additional family members in your household please let us know. First Name Last Name Date of birth MM DD YYYY Relationship Type of visa held PPS Number Additional Family Members in Household First Name Last Name Date of birth MM DD YYYY Relationship Type of visa held PPS Number Emergency Contact First Name Last Name Phone (###) ### #### Identify person looking for assistance * Applicant only Applicant and dependants Do you have health/travel insurance? Yes No Details Please indicate what financial assistance you require: Accommodation $ Utility $ Grocery $ Clothing $ Medical $ Other $ Please specify Total $ Your income - Employment Amount How often? Centrelink Amount How often? Income protection insurance/ other insurance Amount How often? Other income sources Please give details Please describe your personal situation and reasons for requiring assistance: Have you made attempts to secure funds from friends and family? Please provide details: Do you have any other information you would like to include, e.g. extenuating circumstances, Health issues etc. Accommodation Assistance (Please tick appropriate box) Home owner Boarding house Private house/ Apartment Hostel House share Age care facility Rent/Mortgage per week $ Estate Agent/Landlord (if applicable) Name Address: Postcode: Telephone: Email Consent * Please tick to confirm you have read and agree to the following statements. I consent for the ISA staff to contact other individuals and agencies on my behalf if required. The staff member will provide details verbally or in writing before information is shared with others. I understand that staff may contact appropriate agencies and individuals on my behalf without consent if they have reasonable belief that there is a risk to my health and safety, or that of another person, or if there is a legal requirement to do so. I confirm that all information above is correct and that I have not withheld information about my finances including savings accounts, other income or expenditures. Date MM DD YYYY Thank you!