Better health and ageing for all Australians

Aged Care Forms

Application for Financial Hardship Assistance - Residential Aged Care - Text Version

Below is the text from the Application for Financial Hardship Assistance form for accessibility purposes.

Please print the form and use this text to assist in completing the form.

PDF printable version of the Application for Financial Hardship Assistance form (PDF 646 KB)

Page 1

Aged Care Application for Financial Hardship Assistance

If you are a resident in an aged care home and have difficulty paying your care fees or accommodation payment, you may be eligible for financial assistance under the hardship provisions of the Aged Care Act 1997 (the Act):
  • because of circumstances beyond your control; or
  • because you have used your financial resources to pay essential expenses, such as pharmaceuticals.
Except in exceptional circumstances hardship assistance would not be granted in the following situations:
  • when a resident (or their representative) chooses not to use assets to help pay their care fees, for example, when a resident chooses not to realise an asset because it is earmarked for inheritance purposes;
  • when a resident has personal debts; or
  • when a resident gifts money/assets before or after entering care, that is, money/assets which could be used to pay their care fees or accommodation payments.
The types of available assistance are:
  • a reduction in basic daily fee
  • assistance with income tested fee
  • assistance with an accommodation bond or accommodation charge.
Hardship assistance is not available for residents occupying an extra service place.

If you wish to continue with this application, please complete this form and return it to the Department of Health and Ageing (the Department) at the address shown on page 4. Another person may complete this form on your behalf.

Part A – Resident’s Details

Resident’s Family name:
Given names:
Date of Birth:
Marital Status – widowed, divorced, married/partnered, separated, single:
Date of permanent entry into aged care home:

If you receive a pension/benefit from Centrelink or the DVA, please write your reference number:
Centrelink Reference Number:
DVA Reference Number:

Name of aged care home where the applicant resides:
Phone number:
Address of aged care home:
Postcode:

For help completing the form, please phone 1800 020 103 (free call).
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Page 2

Part B – What you should provide

  • If requesting a reduction in your basic daily fee please tick this box and provide the information listed under (ii) below.
  • If requesting assistance with your income tested fee please tick this box and provide the information listed under (ii) below.
  • If requesting assistance with your accommodation bond please tick this box and provide the information listed under (iii) below.
  • If requesting assistance with your accommodation charge please tick this box and provide the information listed under (iii) below.
All applicants must answer section (i).

Applicants with a partner/spouse:

The Act states that when a resident has a partner/spouse, the resident is considered to:
  • earn half their combined income, no matter which partner actually receives or earns the income;
  • own half their total assets, no matter who holds title to the assets.
Applicants should therefore provide details of their partner’s income and assets as well as details of their own income and assets.

(i) All applicants

Have you or your partner gifted cash or assets before or after you entered permanent aged care?

Yes (please attach explanation)
No

(ii) If requesting a reduction in your basic daily fee and/or assistance with your income tested fee, please provide the following:

  • proof of essential expenses, that is the expenses you and your partner (if applicable) cannot avoid.
For example:
    • residential care fees and accommodation payments
    • pharmaceutical expenses (please include itemised chemist’s accounts for the last three months)
    • continence aids (if not provided free of charge)
    • income tax currently paid
    • mortgage payments
  • evidence of your income from all sources, including copies of recent bank statements for all accounts (Also provide details of your partner’s income, if applicable.)
  • statements for all accounts, and details of shares, investments, property owned and collectables (Also provide details of your partner’s assets, if applicable.)
  • Are any of your assets unrealisable (that is, cannot be sold, rented or borrowed against)?
Yes – please explain why they cannot be realised and provide evidence, for example, letters from a real estate agent or retirement village agent.
No

Page 3

(iii) If requesting assistance with your accommodation bond or accommodation charge, please provide the following:

  • copies of current statements for all bank accounts;
  • documentary evidence of property owned. The value of the property and its market rental rate should be confirmed in writing by a real estate agent; and
  • if your home is a retirement village unit, a copy of the exit entitlement statement.
Have any of your assets proved to be unrealisable (that is, could not be sold, rented or borrowed against) since you entered permanent aged care?

Yes – please explain why they have proved to be unrealisable, for example, letters from your real estate agent or retirement village agent.
No

Part C – Please explain why you are applying for hardship assistance.

(You may also attach a letter explaining your reasons.)Blank area for written explanation.

Part D – Checklist

(tick relevant boxes)

If requesting a reduction in your basic daily fee and/or assistance with your income tested fee, have you provided:

Proof of essential expenses: Yes
List of assets: Yes
Evidence of current income: Yes
Evidence of any tax paid: Yes

If requesting assistance with an accommodation bond or assistance with an accommodation charge, have you provided:

Copies of current bank account statements: Yes
Documentary evidence of property owned: Yes
Letters confirming the value of property owned and its market rental rate: Yes
Copy of exit entitlement statement: Yes

Please note: Failure to provide documentary evidence may result in delays in processing your application.

Please complete the back page
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Page 4

Part E – Authority to release information

To assess your application, the Department will ask Centrelink or the DVA for information about your income and assets. Your authorisation is required to permit Centrelink or DVA to release this information.

I authorise Centrelink or the DVA to release to the Department of Health and Ageing information about my income and assets.

Signature:
Date:

Authorised representatives: If an authorised representative is making this application on behalf of a resident, please attach a copy of the document authorising you to act on behalf of the resident, for example, Power of Attorney form.

Please provide your name and contact details

(we may need to contact you)

Family name:
Given names:
Telephone (day time only):
Email:
Relationship to aged care resident:
Signature of authorised representative:
Date:

Authorised representatives:

Have you attached a copy of your Power of Attorney or other authorising document? Yes

Part F – Declaration

Declaration

I declare that the information provided in this application is true and correct. I understand that giving false or misleading information to the Commonwealth is a serious offence and paragraph 137.1(1) of the Commonwealth Criminal Code provides for a penalty of 12 months imprisonment.

Signature of applicant or authorised representative:
Date:
Address for correspondence:
Postcode:
Phone number:

Please return this form to:

Director, Resident Liaison Section
MDP 551 (Hardship)
Ageing and Aged Care Division
Department of Health and Ageing
GPO Box 9848
CANBERRA ACT 2601

For help in completing this form, please phone 1800 020 103 (free call).

An information sheet on financial hardship assistance is available at the Department of Health and Ageing website
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