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Rates Deferral (Hardship) Application Form

Rates Deferral (Hardship) Application Form

If you're a property owner who is not a pensioner and is experiencing significant financial hardship, each year you can apply to defer your rates under the Rates Act 2004.

Please complete the following application to apply for a rates deferral (hardship) assistance of your rates at the ACT Revenue Office

All fields marked ( * ) are mandatory.

Owner details

Owner's name: *

Date of birth: *

Day Month Year

Owner's name:

Date of birth:

Day Month Year

Property details

Suburb: * Section: * Block: * Unit:

Rates account number: *

Property address: *

Is this property your principal place of residence? *

If the property is not your principal place of residence you are not eligible for a deferral of rates.
Please submit a Land Tax Notification Form.

Please indicate which charges you would like deferred: *

Rates arrears
Current year's rates

A rates deferment on hardship grounds can only be approved for up to 12 months, a new application
must be submitted with the Commissioner for ACT Revenue each year.

Contact details

Postal address: *

Contact email: *

Telephone: *

Financial information

What is the estimated current market value of the property? *

Is there a mortgage over the property? *

Lending institution: *

Amount outstanding: *

Monthly repayments: *

Arrears: *

Savings: *

Please provide total savings from all bank accounts, term deposits and investment accounts.

Assets

List all assets and their current value (eg. motor vehicles, boats, caravans, trailers, motor bikes)

Asset 1 Value

Asset 2 Value

Asset 3 Value

Asset 4 Value

Monthly Income

Provide details of all monthly gross income sources including: Employers, pensions, allowances,
rental income, maintenance payments, share dividends and interest.

Income source Monthly income

Monthly Expenses

Food *

Utilities *

Travel *

Education *

Medical *

Insurance *

Telephone *

Credit card *

All other monthly expenses:

Dependents

(please list all dependents names and ages)

Dependent 1

Dependent 2

Dependent 3

Dependent 4

Dependent 5

Dependent 6

Compensation and third party claims

Do you have an outstanding compensation/third party claim? *

Insurance company:

Claim number:

Please provide details surrounding your claim:

Attachments

Please attach all supporting documents listed below: *

Statement requesting hardship assistance
Mortgage/home loan documents
Bank statements (last 6 months)
Evidence of arrears
Evidence of income
The most recent years tax returns
Monthly expenses
Compensation and third party claims documentation (if applicable)

Declaration

I/we: *

Declare that:

I/we declare that the information in this deferral application is true, correct and complete and that I/we have self-assessed my/our eligibility for a deferral.
I/we agree that be submitting this application under Section 46 of the Rates Act 2004, I am/we are applying to defer my/our rates.
I/we authorise the ACT Revenue Office to verify the details provided to substantiate this application.
I/we acknowledge that under section 338 of the Criminal Code 2002, giving false or misleading information is a serious offence and I will notify the Commissioner for ACT Revenue in writing and provide full details if there is a change in my/our circumstances during the financial year. This includes a change of address and contact details.

Privacy Statement

Information collected by the ACT Revenue Office (ACTRO) is protected by secrecy provisions contained in Acts administered by the ACTRO, including the Taxation Administration Act 1999, and is used for the purposes of administering those Acts. In addition, personal information provided to the ACTRO is protected by the Information Privacy Act 2014. Information (including personal information) is not disclosed to any third party without the consent of the person involved, unless authorised by law. For example, the ACTRO may disclose tax information in connection with the administration of a tax law, or may be required to disclose information to organisations that have legal authority to require the information in prescribed circumstances, including for law enforcement purposes.

Please read our Privacy Policy which sets out how personal information is collected, used and disclosed by the Commissioner for ACT Revenue and the ACT Revenue Office, how you may access and seek correction of your personal information, and how you may complain about breaches of privacy.

Contact us

If you require further information on Rates Assistance and your application, please contact the ACT Revenue Office by clicking here or call us on (02) 6207 0028.