Clean-Up Assistance Program EOI Form Preview Clean-Up Assistance for Uninsured Residents - Expression of Interest * indicates a required field Following Tropical Cyclone Seroja assistance is available for eligible uninsured residents for the removal of disaster related debris from their homes to make them safe and habitable. The following expression of interest is intended to gauge the level of interest in the impacted communities for uninsured residents for the removal of disaster related debris. This is not an application for immediate assistance. In some cases assistance may be available for the demolition of uninsured homes that have been destroyed or significantly damaged. Recovery and Resilience Officers will be in contact with you regarding your expression of interest. Eligibility criteria apply. Recovery and Resilience Officers can be reached at [email protected]. This assistance is being provided through the jointly funded Commonwealth-State Disaster Recovery Funding Arrangements (DRFA). Eligibility Is the property impacted by TC Seroja insured? * ○ Yes ○ No Please note: if you answered yes you are not eligible for this grant. Local Government Area * ○ Shire of Carnamah ○ Shire of Koorda ○ Shire of Carnarvon ○ Shire of Mingenew ○ Shire of Chapman Valley ○ Shire of Morawa ○ Shire of Coorow ○ Shire of Mount Marshall ○ Shire of Dalwallinu ○ Shire of Northampton ○ Shire of Dandaragan ○ Shire of Perenjori ○ City of Greater Geraldton ○ Shire of Shark Bay ○ Shire of Irwin ○ Shire of Three Springs ○ None of the above Please note: if your residence was not in one of the 16 LGA's listed above you are not eligible for this grant. Personal Information * indicates a required field Applicant * Page 1 of 3 Clean-Up Assistance Program EOI Form Preview Title First Name Last Name Street/Lot Number * Street Name * Suburb * Post Code * Must be a number. Your Email * Must be an email address. Your contact phone number * Alternate contact number Will debris be on your property or will you need the debris collected from the verge? * ○ Debris is on property ○ Collect from verge Does the debris include asbestos or other hazardous material? * ○ Asbestos ○ Hazardous material ○ Both ○ None Would you like a support worker to be available to help with filling out forms? * ○ Yes ○ No Would you like a support worker to be available when debris is cleared? * ○ Yes ○ No Comments Page 2 of 3 Clean-Up Assistance Program EOI Form Preview Please enter any information you think is relevant to your situation. I declare the information provided in this application and attachments, and any details subsequently provided, is true and correct. * ○ I confirm I declare I am the resident of the property damaged by STC Seroja listed on this application. * ○ I confirm I authorise the Department of Fire and Emergency Services to seek any additional relevant information it may require to process this application. * ○ I consent I hereby request and authorise any parties to supply such information as requested by the Department of Fire and Emergency Services. * ○ I consent Ineligible Ineligible Unfortunately, based on your answers you do not meet the criteria for this assistance. Please feel free to contact one of our Recovery and Resilience Officers for further information on other financial assistance you may be eligible for at [email protected] Thank you Page 3 of 3.