Wearne Trust Application for Financial Assistance

Name
This field is for validation purposes and should be left unchanged.
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 Applicant 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 Applicant or the Applicant'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 Applicant’s health) will be collected, used and held pursuant to the Wearne Trust’s Privacy Policy.
By ticking this box I declare that the Applicant or the Applicant’s Parent/Legal Guardian has read and understood the Wearne Trust’s Privacy Policy .*
Privacy Policy
- Yes

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 Applicant’s symptoms or diagnosis
- information about a health service the Applicant had or will receive
- specialist reports and test results
- prescriptions and other pharmaceutical products
- dental records
- the Applicant’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 Applicant to collect their health information for the purposes of this application*
- Yes
I have gained the express consent from the Applicant’s parent/legal guardian to collect the Applicant’s health information for the purposes of this application*
- Yes
Privacy Policy

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

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

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

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 an Applicant.
Organisation/Agency*
Contact Name*
First Last
Position within Organisation/Agency*
Contact Phone*
Contact Email*
Enter Email Confirm Email

Applicant Details
Name of Applicant*
First Last
Applicant Address*
Street Address City State / Province / Region ZIP / Postal Code
Applicant DOB*
Day
Month
Year
This field is hidden when viewing the form
Applicant Age
If Applicant is under 18 and not living independently then provide
Name of Parent or Guardian of the Applicant
Name of Applicant
First Last
Applicant Address
Street Address City State / Province / Region ZIP / Postal Code
Applicant DOB
Day
Month
Year
This field is hidden when viewing the form
Applicant Age
Name of Applicant
First Last
Applicant Address
Street Address City State / Province / Region ZIP / Postal Code
Applicant DOB
Day
Month
Year
This field is hidden when viewing the form
Applicant Age

Financial Assistance Being Requested

All quotes are to be provided in the name and address of the Applicant.
Priority
Item
Amount
Note for whitegoods items:
- Applicants living in regional areas apply on-line using this form.
- Applicants living in metropolitan area do not use this form to apply for assistance with whitegoods. They must apply to:
  Lindsay Boyer
  State Manager – Doorways WA
  The Salvation Army Australia Territory
  Mob: 0457 409 878
  PO Box 317 Morley WA 6943
  Email: Lindsay.boyer@salvationarmy.org.au
Please Specify*
Priority
Item
Amount
Note for whitegoods items:
- Applicants living in regional areas apply on-line using this form.
- Applicants living in metropolitan area do not use this form to apply for assistance with whitegoods. They must apply to:
  Lindsay Boyer
  State Manager – Doorways WA
  The Salvation Army Australia Territory
  Mob: 0457 409 878
  PO Box 317 Morley WA 6943
  Email: Lindsay.boyer@salvationarmy.org.au
Please Specify*
Priority
Item
Amount
Note for whitegoods items:
- Applicants living in regional areas apply on-line using this form.
- Applicants living in metropolitan area do not use this form to apply for assistance with whitegoods. They must apply to:
  Lindsay Boyer
  State Manager – Doorways WA
  The Salvation Army Australia Territory
  Mob: 0457 409 878
  PO Box 317 Morley WA 6943
  Email: Lindsay.boyer@salvationarmy.org.au
Please Specify*
Priority
Item
Amount
Note for whitegoods items:
- Applicants living in regional areas apply on-line using this form.
- Applicants living in metropolitan area do not use this form to apply for assistance with whitegoods. They must apply to:
  Lindsay Boyer
  State Manager – Doorways WA
  The Salvation Army Australia Territory
  Mob: 0457 409 878
  PO Box 317 Morley WA 6943
  Email: Lindsay.boyer@salvationarmy.org.au
Please Specify*
Total

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

Persons living with the applicant
Do you have any dependents or others living in the household?*
- Yes
- No
Provide details of all persons living in the house occupied by the Applicant.
- include ANY spouse, partner, child, parent, guardian, sibling, friend or other persons.
- Fortnightly Income of each person if not stated in the Statement of Applicant Household Income - Next section
Name
First Last
DOB
Day
Month
Year
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Age
Relationship to Applicant
Fortnightly Income
Name
First Last
DOB
Day
Month
Year
This field is hidden when viewing the form
Age
Relationship to Applicant
Fortnightly Income
Name
First Last
DOB
Day
Month
Year
This field is hidden when viewing the form
Age
Relationship to Applicant
Fortnightly Income
Name
First Last
DOB
Day
Month
Year
This field is hidden when viewing the form
Age
Relationship to Applicant
Fortnightly Income
Name
First Last
DOB
Day
Month
Year
This field is hidden when viewing the form
Age
Relationship to Applicant
Fortnightly Income
Name
First Last
DOB
Day
Month
Year
This field is hidden when viewing the form
Age
Relationship to Applicant
Fortnightly Income
Name
First Last
DOB
Day
Month
Year
This field is hidden when viewing the form
Age
Relationship to Applicant
Fortnightly Income
Applicant is single occupant of household*
- Yes
- No
This field is hidden when viewing the form
Total Fortnightly Income

Statement of Applicant Household Income and Expenses

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

“Relevant Person” means:
1. any person that ordinarily resides in the Recipient’s household (excluding any person who is just a boarder); and
2. who is either dependent on the Applicant or is a person upon whom the Applicant is financially dependent.
Income - Applicant's Household
Per Fortnight
Income - Applicant
Wage/Pension 1*
Wage/Pension 2*
Government / Family Payment*
Board/Rent Received*
Child Support*
Other Income*
Sub Total Applicant Income
Income - Other Relevant Persons
Person 1
Wage/Pension 1*
Wage/Pension 2*
Government / Family Payment*
Board/Rent Received*
Child Support*
Other Income*
Person 2
Wage/Pension 1*
Wage/Pension 2*
Government / Family Payment*
Board/Rent Received*
Child Support*
Other Income*
Sub Total Relevant Persons Income

Expenses - Applicant's Household
Per Fortnight
Housing
Rent*
Mortgage Payments*
Insurance*
Utilities: Water*
Utilities: Gas*
Utilities: Electricity*
Home Phone / Internet*
Mobile Phone*
Home Maintenance*
Transport / Vehicle
Car Loan Payments*
Car Expenses (Insurance/ License/Repairs)*
Fuel*
Public Transport*
Taxi / Rideshare e.g. Uber*
Groceries
Groceries & General 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)

Expenses - Applicant's Household Continued
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*
Union Fees*
Other Payments
Child Support*
Tax Debts*
Fines*
Union Debts*
Centrelink Repayment*
Credit Card 1*
Credit Card 2*
Store Account 1*
Store Account 2*
Personal Loan 1*
Personal Loan 2*
LayBy / Afterpay*
Other Debts*
Other Court Ordered Payment(s)*
Sub Total
Sub Total (2)

Income and Expenditure Statement Totals
Per Fortnight
Totals
Sub Total Expense (1)
Sub Total Expense (2)
TOTAL HOUSEHOLD EXPENSES
Sub Total Income Applicant
Sub Total Income Related Person
Sub Total Income Persons Living with the Applicant
TOTAL HOUSEHOLD INCOME
SURPLUS (OR SHORTFALL)
(Total Income minus Total Expenditure)

Statement of Assets and Liabilities

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 Applicant’s household (except any person who is just a boarder); or
2. any person upon whom the Applicant is financially dependent.
Assets
“Assets” means total value of each item owned as per list or other items not listed
House*
Brief Description
Household Effects*
Brief Description
Car(s)*
Brief Description
Motor Bike(s)*
Brief Description
Boat*
Brief Description
Other Property*
Brief Description
Shares*
Brief Description
Bank Deposits / Savings*
Brief Description
Cash*
Brief Description
Total
Total Assets
Liabilities
“Liabilities” means all debts owed by the Applicant, owed by a Relevant Person or jointly owed by them.
List must Include all debts whether the debts are identified in expenses as being paid off by instalments or not.
Home Loan Mortgage*
Brief Description
Rent Arrears*
Brief Description
Car Loan*
Brief Description
Credit Card 1*
Brief Description
Credit Card 2 + more*
Brief Description
Store Account 1*
Brief Description
Store Account 2*
Brief Description
Personal Loan 1*
Brief Description
LayBy/Afterpay*
Brief Description
Other Loan(s)*
Brief Description
Child Support*
Brief Description
Tax Debts*
Brief Description
Fines*
Brief Description
Court Ordered payments*
Brief Description
Centrelink Debt*
Brief Description
Other Debts*
Brief Description
Total
Total Liabilites

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

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*
If supplier requires another payment method, please email the Wearne Trust at info@wearnetrust.org.au to arrange an alternative payment method.

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.

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). The quotes must be provided from different suppliers.
Drop files here or

Accepted file types: jpg, gif, png, pdf, doc, docx, Max. file size: 16 MB.
All quotes are to be in the name and address of the Applicant. If not able to provide the address, please provide a reason
- Yes
- No
Reason*
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.
Payment details for the supplier must be provided or the application will not be processed
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.
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Date
DD dash MM dash YYYY

Step 1 of 16

Terms of the Application (Application)

Privacy Policy

Representative Details

Applicant Details

Financial Assistance Being Requested

Background Circumstances

Persons living with the applicant

Statement of Applicant Household Income and Expenses

Income - Applicant's Household

Income - Applicant

Income - Other Relevant Persons

Person 1

Person 2

Expenses - Applicant's Household

Housing

Transport / Vehicle

Groceries

Medical

Sub Total

Expenses - Applicant's Household Continued

Education

Personal

Other Payments

Sub Total

Income and Expenditure Statement Totals

Totals

Statement of Assets and Liabilities

Assets

Total

Liabilities

Total

Payment Details of Supplier

Supplier 1

Supplier 2

Supplier 3

Supplier 4

Documentation

Submission Deadlines and Approvals

Submission Deadlines and Approvals

Financial Assistance Applications

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