Freedom of Information 
Statement of hardship form 
 
FOI Reference: 
 
 
  
 
I enclose a cheque or money order for the amount of $28.40, made payable to the Department of Health & 
Human Services as payment of the freedom of information application fee. 
OR 
 
 
Statement of hardship. The payment of the application will cause me hardship because:  
 
 
 
 
 
 
 
 
I also include a copy of my identification document. 
 
Signed: 
 
 
Dated: 
 
 
Name: 
 
 
Telephone:   
 
Address 1:   
Address 2:   
 
 
Please send payment or completed statement of hardship to: 
Freedom of Information unit 
Department of Health and Human Services 
GPO Box 4057 
Melbourne Victoria 3001 
 

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