Application for Permanently Impaired Gift

Information regarding eligibility and additional application forms can be found at

www.dhs.vic.gov.au/bushfireappeal or by calling 1800 180 213.

When completed:

Post: Victorian Bushfire Appeal Fund

GPO Box 4057
Melbourne 3001

Fax: (03) 9092 1926

Email: vicbushfireappealfund@dhs.vic.gov.au

TO COMPLETE THIS APPLICATION PLEASE SIGN THE PRIVACY STATEMENT, PERMISSION TO

ACCESS MEDICAL RECORDS AND THE DECLARATION ON PAGES 13 AND 14.

APPLICATIONS CLOSE ON 28 FEBRUARY 2011.

Applicant’s Details (Note that if you are a parent/guardian applying on behalf of a minor please enter
their details as the primary applicant).

Name: ……………………………………………………………………………………………………………………………………………………

Date of birth: ………...../………...../………..... Gender: Male Female

Your current residential address:

Street No. and Name: …………………………………………………………………………………………………………………………….

Suburb: …………………………………………………………………… Postcode: ……………………………………………………

City: ………………………………………………………………………. State: …………………………………………………………

Home Phone: …………………………………………………………. Mobile Phone: ……………………………………………………

Email address: ………………………………………………………………………………………………………………………………………..

Do you receive a Centrelink benefit? YES NO

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If Yes, please indicate the type of benefit.

Partners or Widows Seniors or Retired Bereavement Carers

Other (please describe below)

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Bank Details (these will be used to make a payment to you if you are eligible for this gift):

Account Name: ………………………………………………………………………………………………………………………………

Bank: ………………………………………………………… Branch: ……………………………………………………………….

BSB: …………………………………………………………. Account Number: ………………………………………………….

How many people are there in your household? 1 2 3 4+

How many people in your household have a 0 1 2 3 4+

healthcare card? Please attach a copy of the
healthcare card of any household members.

How many children 18 years or under are financially 0 1 2 3 4+

dependent on you?

How many other people are financially dependent 0 1 2 3 4+

on you?

Are you a single parent? YES NO

Are other people in your household likely to apply YES NO

for this gift as well?

Identification – Please indicate the type of identification provided and include a photocopy with your
application (Note: If you have had a previous claim with the Victorian Bushfire Appeal Fund, you do not
need to provide proof of identification)

Driver’s Licence Passport

Medicare card Concession card
Other (provide details):

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Injury details – General

Did you receive a Severe Injury Payment? YES NO

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 Were you admitted to hospital as an inpatient* within 12
months of the 2009 Victorian bushfires for an injury you
sustained as a direct result of the bushfires? YES NO

* Inpatient means you were admitted to a hospital or clinic for treatment that requires at least one overnight stay

Which type of injury did you sustain as a direct result of the 2009 Victorian bushfires that may have resulted
in a permanent impairment? Please place a tick in the appropriate box below.

Note: For the purposes of this gift a permanent impairment is assessed based on physical or
psychological injuries (it cannot be a combination of both). Please complete this form providing
details of the physical or psychological injuries that have affected you the most, resulting in a
permanent impairment. However, you can provide details of any other injuries sustained as a direct
result of the 2009 Victorian bushfires in the Additional Information section of Part A or Part B.

Physical injury – Please complete the questions in Part A

Psychological injury – Please complete the questions in Part B

All applicants must complete Part C, Part D and Part E.

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PART A - PHYSICAL INJURY

What date did you receive your injury? ………...../………...../……….....

Please provide a brief description below and attach any relevant medical records to evidence your injury
and how it relates to the 2009 Victorian bushfires (if you do not have enough room below please attach a
separate sheet).

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Had you suffered this injury, or a similar injury, prior to the 2009 YES NO
Victorian bushfires?

If Yes, provide a brief description below and attach any relevant medical records to evidence your previous
injury (if you do not have enough room below please attach a separate sheet).

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What was the name of the hospital where you were admitted following the 2009 Victorian bushfires (if
you have a copy of your hospital invoice, please attach it to this application)?

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What date/s were you admitted to hospital: ………...../………...../………..... to ………...../………...../……….....

Ongoing Treatment and Impact on Daily Living

Please provide a brief description of the ongoing treatment required for your injuries and attach any
relevant medical records or other supporting evidence (if you do not have enough room below please
attach a separate sheet).

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Please provide a brief description of how your injury has affected your activities of daily living (for
example, physical activity, self-care, personal hygiene, communication, and social and recreational
activities).

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Additional Information

Is there any other information you think is relevant to your permanent impairment? If so, please briefly
describe below.

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Other Supporting Material

Please attach any other medical documents that will help us to assess your application. Examples include
a hospital report or a letter from your treating physician or General Practitioner (GP).

If you are unsure whether the level of documentation you currently have in relation to your injuries will be
sufficient for your application, and you need help obtaining an up to date summary of medical information
about the treatment provided to you for your injury/ies, you may decide to discuss this with your treating
physician or GP.

Note: It is not necessary for your treating physician or GP to undertake a medical examination. The
decision to perform a medical examination is at the discretion of your treating physician or GP.

In these cases, your treating physician or GP may assist you to complete Part A or Part B of the application
form. Alternatively, they may prefer to write a letter containing the relevant information, and if so you
should attach this letter to your application.

Note: The Victorian Bushfire Appeal Fund has sought advice from the Commonwealth Government which
has advised that consultations with a GP can be claimed for this purpose under Medicare. However, the
benefits you receive from Medicare are based on a Schedule of fees set by the Australian Government.
Your treating physician or GP may choose to charge more than the Schedule fee.

Processing of your application may be delayed if you do not attach supporting documents.

Applicants may be referred for an independent expert medical assessment.

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PART B - PSYCHOLOGICAL INJURY
Were you admitted to hospital within 12 months of the 2009 Victorian bushfires for an injury you
sustained as a direct result of the bushfires (please tick)?

YES NO

Did you require both prescribed medication and therapy with a psychiatrist or psychologist at least weekly
for a minimum of 12 weeks within 12 months of the 2009 Victorian bushfires for an injury you sustained as
a direct result of the bushfires (please tick)?

YES NO

If you answered NO to both of the questions above, then you are not eligible for this gift.

Please provide a brief description below and attach any relevant medical records to evidence your injury
and how it relates to the 2009 Victorian bushfires (if you do not have enough room below please attach a
separate sheet).

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Had you suffered this injury, or a similar

psychological injury, prior to the 2009 Victorian
bushfires? YES NO

If Yes, provide a brief description below and attach any relevant medical records to evidence your previous
injury (if you do not have enough room below please attach a separate sheet).

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If you were admitted to hospital within 12 months of the 2009 Victorian bushfires for an injury you
sustained as a direct result of the bushfires:

What date/s you were admitted to hospital: ………...../………...../………..... to ………...../………...../……….....

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What was the name of the hospital where you were admitted (if you have a copy of your hospital invoice
and/or records, please attach it to this application)?

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Ongoing Treatment and Impact on Daily Living

Are you required to take prescribed medication for your psychological injury? YES NO

If yes, please indicate the name of the medication and dosage:

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Does your psychological injury also involve ongoing regular therapy? YES NO

If Yes, how frequently have you received the therapy?

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Please provide a brief description of how your psychological injury has affected your activities of daily
living (for example, physical activity, self-care, personal hygiene, communication, and social and
recreational activities).

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Additional Information

Is there any other information you think is relevant to your permanent impairment? If so, please briefly
describe below.

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Other Supporting Material

Please attach any other medical documents that will help us to assess your application. Examples include
a hospital report or a letter from your treating physician or General Practitioner (GP).

If you are unsure whether the level of documentation you currently have in relation to your injuries will be
sufficient for your application, and you need help obtaining an up to date summary of medical information
about the treatment provided to you for your injury/s, you may decide to discuss this with your treating
physician or GP.

Note: It is not necessary for your treating physician or GP to undertake a medical examination. The
decision to perform a medical examination is at the discretion of your treating physician or GP.

In these cases, your treating physician or GP may assist you to complete Part A or Part B of the application
form. Alternatively, they may prefer to write a letter containing the relevant information, and if so you
should attach this letter to your application.

Note: The Victorian Bushfire Appeal Fund has sought advice from the Commonwealth Government which
has advised that consultations with a GP can be claimed for this purpose under Medicare. However, the
benefits you receive from Medicare are based on a Schedule of fees set by the Australian Government.
Your GP may choose to charge more than the Schedule fee.

Processing of your application may be delayed if you do not attach supporting documents.

Applicants may be referred for an independent expert medical assessment.

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Part C – Household Income, Assets, and Liabilities

Please indicate your household’s income, assets, and liabilities for the last financial year.

Income

What was your household income (if any) for the last financial year?

Less than $40,000 Between $40,001 and $80,000

Between $80,001 and $120,000 Over $120,001

Was there a reduction in your household income as a YES NO

direct result of the 2009 Victorian bushfires?

If so, what was the reduction in your household income as a direct result of the bushfires?

Less than $10,000 Between $10,001 and $25,000

Between $25,001 and $50,000 Over $50,001

Assets

Please indicate your household’s other assets (if any).

Property/s (excluding principle place of residence)

Cash (e.g. bank accounts, insurance payments, Victorian Bushfire Appeal Fund Gifts, etc)

Financial Investments (e.g. bonds, shares, term deposits)

Other (please describe below)

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What is the total value of your household’s assets (excluding your principle place of residence)?

Less than $100,000 Between $100,001 and $200,000

Between $200,001 and $400,000 Between $400,001 and $600,000

Between $600,001 and $800,000 Over $800,001

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Are any of these assets intended to be used to meet your accommodation needs in the next 12 months?
For example, rebuilding your destroyed principle place of residence, purchasing a new principle place of
residence or renting.
YES NO

If YES, what is the total estimated value of the assets intended to be used to meet your accommodation
needs in the next 12 months (please note that amounts over $300,000 may not be considered for the
purposes of determining your financial hardship)?

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Liabilities

Please indicate your household’s liabilities (if any).

Mortgage Bank Loans Credit Cards Personal Loans Other (please describe below)

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What is the total value of your household’s liabilities?

Less than $100,000 Between $100,001 and $200,000

Between $200,001 and $400,000 Between $400,001 and $600,000

Between $600,001 and $800,000 Over $800,001

Determining your financial hardship involves consideration of a range of factors, including your financial
resources and your financial burdens. Eligibility for this gift will be determined through the answers you
provide in this application. However, as a general rule, if your current household income is over $80,000
or your total assets minus liabilities are over $600,000, you would be considered ineligible for this gift.

If you are in this category but believe you should receive the Gift due to significant issues relating to your
exceptional financial needs as a result of your loss, you should provide further information for
consideration below.

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Please indicate which of the following factors are causing you to experience financial hardship (more than
one may be appropriate)

Accommodation costs (e.g. rent or mortgage payments)

Living costs (e.g. food costs, transports, electricity, gas or water bills)

Medical treatment costs

Other costs associated with impairment (e.g. property or vehicle modifications)

Education costs

Are there any other factors causing you to experience financial hardship? If so, please describe below.

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PART D – Permission to access medical records

Note: Where this application is being completed on behalf of a minor, this section is to be signed by
the parent/guardian.

I grant the Victorian Bushfire Appeal Fund permission to:

• access my medical records for the purposes of confirming information provided in this
application, and for otherwise assessing my eligibility for this gift; and
• contact my healthcare provider/s and confirm with them information provided in this
application, and to otherwise assess my eligibility for this gift.

I agree with the stated purpose: YES NO

Name:
Signature:
Date: / /

To complete your application please ensure you have completed the following:
You have completed Part A (if you have a physical injury) or Part B (if you have a
s psychological injury
You have completed Part C
You have signed the Medical Authorisation Statement in Part D
You have signed the Statutory Declaration and Privacy Statement in Part E
You have attached all relevant medical records to support your application (for
example, hospital admission statements, letters from physicians, etc)
If you consulted a treating physician or GP please attach the documentation provided
by the treating physician or GP
If you have not had a previous claim with the Victorian Bushfire Appeal Fund, you have
provided proof of identification.

Please post your application to the Victorian Bushfire Appeal Fund at:

Victorian Bushfire Appeal Fund

GPO Box 4057
Melbourne 3001

Or fax to: (03) 9092 1926

Or email to: vicbushfireappealfund@dhs.vic.gov.au

Applications close on 28 February 2011. Thank you for completing this application.

Your health information

The Department of Human Services collect your health information for the purpose of assessing your eligibility for this
gift. Information is handled in accordance with the Health Records Act 2001 and will only be used or disclosed for this
purpose or otherwise with your consent, or as required or authorised by law.

For further information about privacy, or to access the information held about you, contact Department of Human
Services (1300 650 172) OR Department of Human Services, Freedom of Information Unit (Freedom of Information Team,
GPO Box 4057, MELBOURNE VIC 3001).

Office Use Only

Application ID:
Signature of grants officer: Date: / /
Signature of approving officer: Date: / /
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PART E – Statutory Declaration and Privacy Statement

Note: Where this application is being completed on behalf of a minor, this section is to be signed by
the parent/guardian.

I .....................................................................................................................................
[full name]

of ...................................................................................................................................
[address]

…....................................................................................................................................
[occupation]

Do solemnly and sincerely declare that:

I acknowledge that this application is true and correct, and

I make it with the understanding and belief that a person who makes a false
declaration is liable to the penalties of perjury.

I understand that:

• the Victorian Bushfire Appeal Fund is collecting information in this application for the
purpose of determining my eligibility for financial assistance.
• this information will not be used without my permission for any other purpose other than
determining eligibility and verifying that the information provided is true and correct.
• if I am unable to provide this information upon request, the Victorian Bushfire Appeal
Fund will be unable to process my application.
• the Victorian Bushfire Appeal Fund may cross-check information you have provided with
its own records and may need to verify the information by contacting councils, insurance
companies, employers, and government and non-government departments agencies and
healthcare providers.
• I can request this information by contacting the Victorian Bushfire Appeal Fund.
• when I provide the Victorian Bushfire Appeal Fund with information about other
individuals, the Victorian Bushfire Appeal Fund relies on me to make these individuals
aware that such information has been provided to the Victorian Bushfire Appeal Fund as
part of the application process.

I agree with the stated purpose: YES NO

Declared at ......................................................................................................................

In the State of Victoria, this ……………………………………….. Day of ………………………………20………..

…………………………………………………………………………………
Signature of person making this declaration
[To be signed in front of an authorised witness]

Before me, …………………...........................

[Signature of authorised witness]
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……………………………………………………………
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[Name address and title of authorised witness]

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