Name *

First Name

Last Name

Reason for Requesting Payment Assistance *

You are ill, or have been ill (recently)

Someone in your household is ill or has been ill

An unexpected event or unforeseen change has reduced your income

An unexpected event or unforeseen change has increased your expenditure

There has been a change in your personal circumstances

There has been a change in your family circumstances

There is, or has been, a natural disaster

Other

Options *

Option 1 - I wish to change the date my next direct debit payment processing (note this does not effect other future scheduled payments)

Option 2 - I would like to make a change to my regular direct debit payment dates (note this will affect all future scheduled direct debit payments)

Option 3 - I wish to change my direct debit frequency - weekly / fortnightly / monthly (note your current payment amount will be pro rated)

Option 4 - I would like to reduce my agreed direct debit installments by up to 50% for a period not exceeding three months

Option 1 - If you have selected Option 1 please advise the date you would like your next payment scheduled to

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DD

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Option 2 - If you have selected Option 2 please advise which day or the week you would like your payments debited

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DD

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Option 4 - If you have selected Option 4 please advise the earliest date you would like your payment reductions to start (noting the reduction will start from your next scheduled payment date)

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DD

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