Emergency Relief Data Collection Form

Emergency Relief enquiries are being processed over the phone for your convenience. If you prefer to have a face to face appointment at our Baulkham Hills office please contact us to arrange an appointment. Please provide ALL documents. Once we receive your enquiry and ALL of your documents, we will call you to discuss assistance.

Please call us if you have any queries 02 9639 8620 or email support@hca.org.au

Eligibility and Consent

Experiencing a short term financial crisis
Reside in one of the following LGAs
- Hills Shire
- Blacktown
- Parramatta
- Hawkesbury

Consent

The information you provide on this form includes your personal information. Your personal information is protected by law, including by the Commonwealth Privacy Act. We are using an IT system called the 'Data Exchange' (DEX) to store your information. This system is hosted by the Australian Government Department of Social Services (DSS). The personal information that is stored on the Data Exchange is only disclosed to us for the purpose of managing your case. You do not have to consent to sharing your personal information with DSS. If you do not consent to us sharing your personal information, it will not affect the services you receive. If you do consent to sharing your personal information with DSS, you can ask for this information to be removed at any time. DSS de-identifies your data. This means they remove information that identifies you or that could be used to re-identify you (e.g. your name). DSS combine your data with other clients' data in the Data Exchange to identify trends at the program level. This information is used to develop policy, administer grants programs, and conduct research and evaluations. DSS may use this data to produce reports. These reports may be shared with other organisations. The data in these reports is de-identified. You can find more information about how DSS will manage your personal information in the DSS privacy policy on their website. Refer to www.hca.org.au for our data privacy statement.

I agree for DEX to collect personal information from the Hills Community Aid *

YesNo

At Risk of Homelessness

YesNo

Have you been impacted by Family/Domestic Violence? *

YesNoPrefer not to Answer

Person Details

First Name *

Last Name *

Street Number/Name *

Suburb *

Post Code *

Phone Number *

Email Address

Date of Birth *

Gender *

How did you hear about HCA? *

Partner's Name

Partner's Date of Birth

Partner's Phone

Demographic Information

Country of Birth *

Primary Language *

Aboriginal or Torres Strait Islander *

Disability *

Housing Type *

Household *

Number of Dependents

Residency Status *

Visa Type

Date Arrived in Australia

Income /Employment/Education

Source of Income *

Centrelink Payment Type eg JobSeeker

Centrelink Reference Number

Employment *

Income Amount (Fortnightly) *

Education *

Required Documents

Recent Centrelink Income Statement or payslips
Copy of Visa if applicable
Proof of Address if not on above documents (eg ID, lease, bill or bank statement)

Other comments or information

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