Wearne Trust Application for Financial Assistance

ONLY APPLICATIONS SUBMITTED THROUGH THE WEBSITE APPLICATION FORM WILL BE CONSIDERED. WRITTEN APPLICATIONS THAT ARE COMPLETED AND EMAILED WILL NOT BE CONSIDERED.

APPLICATIONS MUST BE SUBMITTED BY A REPRESENTATIVE. SEE THE GUIDELINES FOR FURTHER DETAILS ON REPRESENTATIVES.
Terms of the Application (Application)

1) Assessment of Applications

a. Submission of the Application does not expressly or impliedly mean that The Theodore and Isabella Wearne Charitable Trust Inc. (The Trust) has accepted the Application.
b. The Trust is under no obligation, legal or otherwise to process the Application to a successful conclusion.
c. Each application will be determined on its merits and in compliance with The Wearne Trust’s Guidelines for Financial Assistance for Individuals.

2) Liability

a. The Trust will not be responsible for any direct or indirect loss, injury, claim, liability, or damage related to the use of this site, whether from errors or omissions in the content of this site or any other linked sites, from the site being down or from any other use of the site.
b. The Trust will not be liable for any direct or indirect loss, injury, claim, liability, or damage, arising out of or related to any products, goods, or services received by a Recipient through a successful Application.

3) No representations

a. To the extent permitted by Australian law, The Trust makes no representations or warranties in relation to any goods or services ultimately received by the Recipient through the Trust.
By ticking this box I declare that the Recipient or the Recipient’s parent/legal guardian has read and agrees to The Wearne Trust’s Guidelines for Financial Assistance for Individuals and acknowledges and accepts the Terms of Application above.*
The Wearne Trust’s Guidelines for Financial Assistance for Individuals
- Yes
Privacy Policy

The Wearne Trust respects the privacy of those who apply to the Wearne Trust for assistance. The personal information collected through this form (including sensitive information about the Recipient’s health) will be collected, used and held pursuant to the Wearne Trust’s Privacy Policy.
By ticking this box I declare that the Recipient or the Recipient’s Parent/Legal Guardian has read and understood the Wearne Trust’s Privacy Policy .*
Privacy Policy
- Yes

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Will you be providing any health information with this application?*
Health information includes information or opinion about your illness, injury or disability. Some examples of health information include:
- notes of the Recipient’s symptoms or diagnosis
- information about a health service the Recipient had or will receive
- specialist reports and test results
- prescriptions and other pharmaceutical purchases
- dental records
- the Recipient’s genetic information
- Yes
- No
Are you making this application on behalf of:*
- a minor;
- someone who is legally mentally or physically incapable;
- someone who has limited understanding of English?
- Yes
- No
I have gained the express consent from the Recipient to collect their health information for the purposes of this application*
- Yes
I have gained the express consent from the Recipient’s parent/legal guardian to collect the Recipient’s health information for the purposes of this application*
- Yes
Privacy Policy

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Representative’s Declaration*
By ticking this box, I have:

1. permanently deleted all photos (if any were taken) of documents containing the Recipient’s personal information from any device (which includes ensuring they have been deleted from the deleted items); and
2. returned to the Recipient or destroyed, any hard copies of documents containing the Recipient’s personal information I may have collected for the purpose of the application;

except where explicit consent in writing has been received from the Recipient for such Personal Information to be retained.
- Yes

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Representative Details
Name of Representative*
“Representative” means an individual working or volunteering with an organisation such as a social welfare, charitable or other similar organisation which is assisting a Recipient.
Organisation/Agency*
Contact Name*
First Last
Position within Organisation/Agency*
Contact Phone*
Contact Email*
Enter Email Confirm Email

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Recipient Details
Name of Recipient*
First Last
Recipient Age*
Recipient Address*
Street Address City State / Province / Region ZIP / Postal Code
Name of Recipient
First Last
Recipient Age
Recipient Address
Street Address City State / Province / Region ZIP / Postal Code
Name of Recipient
First Last
Recipient Age
Recipient Address
Street Address City State / Province / Region ZIP / Postal Code

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Name
First Last
Sex
Age
Relationship
Name
First Last
Sex
Age
Relationship
Name
First Last
Sex
Age
Relationship
Name
First Last
Sex
Age
Relationship
Name
First Last
Sex
Age
Relationship
Name
First Last
Sex
Age
Relationship
Name
First Last
Sex
Age
Relationship

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Financial Assistance Being Requested

All quotes are to be provided in the name and address of the Recipient.
Priority
Item
Amount
Please Specify*
Priority
Item
Amount
Please Specify*
Priority
Item
Amount
Please Specify*
Priority
Item
Amount
Please Specify*
Total

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Background Circumstances
Background Circumstances*
Including how the financial assistance will be used and the difference it will make with receiving the assistance.

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Income and Expenditure Statement

Fill in the Income and Expenditure Statement (per Fortnight) below. The amounts should reflect the total sum of the Recipient’s and any Relevant Person’s Income and Expenditure per fortnight.

“Relevant Person” means:
1. any person that ordinarily resides in the Recipient’s household (excluding any person who pays rent or board to the Recipient); or
2. any person upon whom the Recipient is financially dependent.
Income
Per Fortnight
Wage/Pension 1*
Wage/Pension 2*
Government / Family Payment*
Board/Rent*
Child Support*
Other Income*
Total Income

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Income and Expenditure Statement

Fill in the Income and Expenditure Statement (per Fortnight) below. The amounts should reflect the total sum of the Recipient’s and any Relevant Person’s Income and Expenditure.

“Relevant Person” means:
1. any person that ordinarily resides in the Recipient’s household (excluding any person who pays rent or board to the Recipient); or
2. any person upon whom the Recipient is financially dependent.
Living Expenses Part 1
Per Fortnight
Housing
Rent/Mortgage*
Utilities: Water*
Utilities: Gas*
Utilities: Electricity*
Home Phone / Internet*
Mobile Phone*
Home Maintenance*
Transport / Vehicle
Car Payments*
Car Expenses*
Fuel*
Public Transport*
Taxi / Rideshare e.g. Uber*
Groceries
General Groceries (Food)*
Household Items*
Dining Out*
Take-away Meals*
Medical
Health Insurance / Ambulance*
Doctor / Specialist / Dentist*
Allied Health (Physio / Chiro etc)*
Chemist / Medications*
Visual Aids (glasses / contacts)*
Sub Total
Sub Total (1)

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Income and Expenditure Statement

Fill in the Income and Expenditure Statement (per Fortnight) below. The amounts should reflect the total sum of the Recipient’s and any Relevant Person’s Income and Expenditure.

“Relevant Person” means:
1. any person that ordinarily resides in the Recipient’s household (excluding any person who pays rent or board to the Recipient); or
2. any person upon whom the Recipient is financially dependent.
Living Expenses Part 2
Per Fortnight
Education
School / University / Course Fees*
Uniforms / Books / Stationery (etc)*
Child Care*
Personal
Clothing/Shoes*
Toiletries/Cosmetics*
Entertainment: Going Out*
Entertainment: Streaming / Pay TV*
Alcohol*
Cigarettes*
Personal Spending eg Lotto / Gambling*
Memberships / Other Fees*
Other Payments
Child Support*
Tax Debts*
Fines*
Union Debts*
Union Fees*
Centrelink Repayment*
Credit Card 1*
Credit Card 2*
Store Account 1*
Store Account 2*
Personal Loan 1*
Personal Loan 2*
LayBy / Afterpay*
Other Loan(s)*
Other Court Ordered Payment(s)*
Sub Total
Sub Total (1)
Sub Total (2)
Total
Total Expenditure
Net Surplus (or Shortfall)
(Total Income minus Total Expenditure)

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Assets and Liabilities Statement

Fill in the Assets and Liabilities Statement below. The amounts should reflect the total sum of the Recipient’s and any Relevant Person’s Assets and Liabilities.

“Relevant Person” means:
1. any person that ordinarily resides in the Recipient’s household (excluding any person who pays rent or board to the Recipient); or
2. any person upon whom the Recipient is financially dependent.
Assets
“Assets” means total value of each item owned as per list or other items not listed
House*
Household Effects*
Farm*
Car(s)*
Motor Bike(s)*
Boat*
Other Property*
Shares*
Bank Deposits / Savings*
Cash*
Total
Total Assets
Liabilities
“Liabilities” means total amount owed on each item (fortnightly payments towards these items recorded in the Income and Expenditure form)
House*
Farm*
Car(s)*
Motor Bike(s)*
Boat*
Other Property*
Loan 1*
Loan 1 Details*
Loan 2 +*
Loan 2 Details*
Other Debt(s)*
Other Debt Details*
Total
Total Liabilites

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Is the Recipient eligible for other assistance?*
- Yes
- No
Please Specify*
Note: Please attach relevant Government Assistance documentation later in the application
Has the Recipient applied to other charities for this assistance?*
- Yes
- No
Charity*
Amount*
Successful*
Charity
Amount
Successful
Charity
Amount
Successful
Charity
Amount
Successful
Will the Recipient make a financial contribution to this application?*
- Yes
- No
How much will be contributed?*
Has the Recipient applied to the Wearne Trust for assistance previously?*
- Yes
- No
When?*

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Payment Details of Supplier

PLEASE NOTE: RECEIPTS MUST BE PROVIDED TO THE WEARNE TRUST WITHIN 14 DAYS OF THE DATE OF PAYMENT. FAILURE TO DO SO MAY RESULT IN FUTURE APPLICATIONS NOT BEING CONSIDERED.
If supplier requires another payment method, please contact the Wearne Trust at info@wearnetrust.org.au to arrange an alternative payment method.
Supplier 1
Preferred payment method*
- EFT
- bPay
Account Name*
BSB*
Account Number*
Reference/Client Number
BPAY Biller Code*
BPAY Reference Number*
Supplier 2
Preferred payment method
- EFT
- bPay
Account Name*
BSB*
Account Number*
Reference/Client Number
BPAY Biller Code*
BPAY Reference Number*
Supplier 3
Preferred payment method
- EFT
- bPay
Account Name*
BSB*
Account Number*
Reference/Client Number
BPAY Biller Code*
BPAY Reference Number*
Supplier 4
Preferred payment method*
- EFT
- bPay
Account Name*
BSB*
Account Number*
Reference/Client Number
BPAY Biller Code*
BPAY Reference Number*

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Documentation

Please scan and upload the following documents (as relevant to this application).

If documents are not uploaded your application will not be considered.
Quotes
Quotes – one quote per item less than $200, two quotes per item equal to or over $200. Please note the quotes should be for an item of similar description (where item equal to or over $200) and include installation and freight (if applicable). All quotes are to be in the name and address of the Recipient. If not able to provide the address, please provide a reason.
Drop files here or

Accepted file types: jpg, gif, png, pdf, doc, docx, Max. file size: 16 MB.
Supporting Documents
Relevant supporting letters/documents such as landlord, medical professional or allied health professional.
Drop files here or

Accepted file types: jpg, gif, png, pdf, doc, docx, Max. file size: 16 MB.
Copies of bill(s) requesting payment
Drop files here or

Accepted file types: jpg, gif, png, pdf, doc, docx, Max. file size: 16 MB.
Government Assistance documentation such as Centrelink Statement
Drop files here or

Accepted file types: jpg, gif, png, pdf, doc, docx, Max. file size: 16 MB.
Any other relevant information
Drop files here or

Accepted file types: jpg, gif, png, pdf, doc, docx, Max. file size: 16 MB.
Hidden
Date
DD dash MM dash YYYY
Name
This field is for validation purposes and should be left unchanged.

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Step 1 of 15

Terms of the Application (Application)

Privacy Policy

Representative Details

Recipient Details

Financial Assistance Being Requested

Background Circumstances

Income and Expenditure Statement

Income

Income and Expenditure Statement

Living Expenses Part 1

Housing

Transport / Vehicle

Groceries

Medical

Sub Total

Income and Expenditure Statement

Living Expenses Part 2

Education

Personal

Other Payments

Sub Total

Total

Assets and Liabilities Statement

Assets

Total

Liabilities

Total

Payment Details of Supplier

Supplier 1

Supplier 2

Supplier 3

Supplier 4

Documentation

Submission Deadlines and Approvals

Financial Assistance Applications

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