Premiers Grants STC Seroja - Resident Application Form Preview Premier's Grants Severe Tropical Cyclone Seroja - Residential Relief * indicates a required field General information for applicants Please note the following: • Only one (1) grant payment of $4,000 will be made per household. • Where a property was rented/leased, the tenant is the primary resident eligible to apply under this scheme. • Where there are multiple dwellings on a property (such as duplexes, park homes, caravans, units and apartments), each application will be considered on a case by case basis. • All applicants will need to provide supporting evidence that demonstrates the damaged dwelling was their primary residence at the time of the proclaimed natural disaster. • The Department of Fire and Emergency Services has discretion to request photographic or other evidence that demonstrates other structures such as dongas or sheds were used for residential purposes at the time of the proclaimed natural disaster. Applicant details Your name * Title First Name Last Name Your address * Address Page 1 of 6 Premiers Grants STC Seroja - Resident Application Form Preview This is the address of your usual place of residence (the home damaged) Your Email * Must be an email address. Your mobile phone number * Must be an Australian phone number. Other Phone Number Must be an Australian phone number. Do you normally operate a business from your home? * ○ Yes ○ No Does anyone else normally live at the same address? * ○ Yes ○ No If others live with you, please list their name and relationship below If anyone else lived at the damaged residence, please list their name and relationship to you. Name Relationship to the applicant Page 2 of 6 Premiers Grants STC Seroja - Resident Application Form Preview Damage to your residence • Under this scheme a residence is the place you normally live. • It may be owned or rented. • It may be a house, a unit, a park home, or any other permanent dwelling. • It must have been destroyed or significantly damaged by wind, storm surge, inundation or other direct impacts of Severe Tropical Cyclone Seroja (11-12 April 2021). • Destroyed means the residence is considered to be permanently uninhabitable. • Damaged means the residence has sustained physical damage valued at more than $4,000 • If you are unsure whether your normal residence fits this criteria, please email us at [email protected] outlining your situation. Which Local Government Area do you normally live in? * ○ Shire of Carnamah ○ Shire of Carnarvon ○ Shire of Chapman Valley ○ Shire of Coorow ○ Shire of Dalwallinu ○ Shire of Dandaragan ○ City of Greater Geraldton ○ Shire of Irwin ○ Shire of Koorda ○ Shire of Mingenew ○ Shire of Morawa ○ Shire of Mount Marshall ○ Shire of Northampton ○ Shire of Perenjori ○ Shire of Shark Bay ○ Shire of Three Springs Do you own the damaged home or rent/lease it? * ○ I own the damaged residence ○ I rent/lease the damaged residence What do you estimate the level of damage to your residence to be? * $ Must be a dollar amount. Please upload any documents or images you feel may help verify the level of damage * Attach a file: Documents that may help us assess your application include photos, quotes for repairs, or insurance assessments. Bank account details • Please note that the bank account details you provide below will be the account any approved funds will be paid into. • Account name is the name the account is held in, for example F and W Flintstone. Page 3 of 6 Premiers Grants STC Seroja - Resident Application Form Preview • The BSB must contain 6 numbers • Please take a few minutes to check the details are correct. The name of your bank * The branch of the bank where your account is held * Your bank account details * Account Name BSB Number Account Number Must be a valid Australian bank account format. Checklist and supporting documents I have uploaded a copy of at least one (1) of the following documents as proof of my identity * ☐ Current WA drivers licence ☐ Current WA Photo Card ☐ Passport ☐ Citizenship Certificate ☐ Birth Certificate ☐ Other: You must upload a clear and legible copy of at least one of the above documents Proof of identity * Attach a file: I have uploaded a copy of three (3) of the following documents as proof I lived at the damaged residence when STC Seroja hit * ☐ Shire rates notice ☐ Rental/lease agreement ☐ Household bill 1 (eg Synergy, Water Corp, Alinta etc) ☐ Household bill 2 ☐ Other You must upload a clear and legible copy of three (3) of the above documents eg. 2 bills and a rates notice, or 2 bills and a rental agreement. If you are unable to provide the three documents please select Other, and provide supporting information in comment box below. Comments (Other) Page 4 of 6 Premiers Grants STC Seroja - Resident Application Form Preview Proof of residence Attach a file: I have uploaded a copy of my bank statement to verify the account details provided * Attach a file: The document will be used to verify the bank your account is held by and your residential address. We do not need the transaction details. Declaration 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 owner of, or held a formal lease for, the residence damaged in STC Seroja. * ○ I confirm I declare the damaged property was my primary place of residence up to the time of STC Seroja. * ○ 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 confirm I hereby request and authorise any parties to supply such information as requested by the Department of Fire and Emergency Services. * ○ I confirm I confirm I have not deliberately provided false or misleading information in this application. * ○ I confirm I confirm I have read and understood the scheme guidelines and information provided and have obtained clarification about the scheme where needed. * ○ I confirm I understand I may be contacted in future by the Department of Fire and Emergency Services for the purposes of evaluating this program. * ○ I confirm Name of the person making this declaration * Title First Name Last Name Page 5 of 6 Premiers Grants STC Seroja - Resident Application Form Preview Page 6 of 6.