HUME CITY COUNCIL
Payment Plan Request due to Financial Hardship
Personal Details
First name
Last Name
Postal Address
Suburb
Post Code
Email
Phone No.
Combined
Infringement No/s
penalty
amount:
If you are not the person named on the infringement, you must provide written consent from the person named
authorising you to act on their behalf. Your application can not be processed without this authorisation.
The person named on the infringement wil remain liable for the infringement/s should the payment plan not be
approved, or the payment plan defaults.
Financial Details
Are you currently receiving a CentreLink Payment?
☐ YES
☐ NO
Type of pension or benefit?
Do you have a current Pensioner Concession Card, Health Care Card or
Department of Veterans Affairs Card?
*Please attach copy
Select from list
What is the maximum amount you could pay? (Select your preferred payment frequency)
An instalment plan cannot exceed 24 months, or for a Company must not exceed 12 months, and repayments
will reflect this timeframe.
☐ Weekly
(no less than $5.00 or $10.00 for parking offences)
☐ Fortnightly
(no less than $10.00)
☐ Monthly
(no less than $20.00)
Preferred start
(min. 2 weeks from today. No more than 8 weeks
date
from today)
Privacy Statement
The information gathered in the form is used by Council to process the application. To view Council’s Privacy Policy, please either visit a
Council offices or
http://www.hume.vic.gov.au/Disclaimer_Copyright/Privacy_Statement
Please provide details of your income
Income (fortnightly after tax)
Wages / Salary
Government benefit / Pension / Other
allowances
Rental / Investment income
Other income eg income from child support,
family member, friend etc
TOTAL FORTNIGHTLY INCOME
Please provide details of your expenses
Expenses (fortnightly)
Rent / Mortgage / Board (please circle)
Food
Electricity/gas/water/telephone/other bills
Car expenses
Public transport
Medical expenses
Credit card repayments
Insurance repayments
Education expenses
Other loan repayments
Other expenses (give details)
TOTAL FORTNIGHTLY EXPENSES
Please provide details of any exceptional financial circumstances you would like to be considered for this
application and attach any supporting documentation
Privacy Statement
The information gathered in the form is used by Council to process the application. To view Council’s Privacy Policy, please either visit a
Council offices or
http://www.hume.vic.gov.au/Disclaimer_Copyright/Privacy_Statement
Declaration
I understand and acknowledge that:
The information provided in this application is true and correct, and completed to the best of my
knowledge.
A response to my application will be sent by Council in writing to the address provided within 10 working
days.
If my payment plan is approved and I do not make a payment within 14 days of the due date provided in
my payment plan schedule, my payment plan may be cancelled. I understand I may not be entitled to
another payment plan (extension of time to pay, or instalment plan) if my plan is cancelled.
Please tick:
☐ Supporting documentation is attached
☐ A copy of my Pension card / Health Care card / Department of Veterans Affairs Card is attached (if
relevant)
☐ My personal and financial details have been completed in full
Signed
Date:
UPON COMPLETION
Email to:
xxxxxxxxx@xxxx.xxx.xxx.xx
Submit in
At a Customer Service Centre:
person:
1079 Pascoe Vale Rd Broadmeadows
Post to:
Hume City Council
44 Macedon Street Sunbury
PO Box 119
75-95 Central Park Avenue Craigieburn
DALLAS VIC 3047
Privacy Statement
The information gathered in the form is used by Council to process the application. To view Council’s Privacy Policy, please either visit a
Council offices or
http://www.hume.vic.gov.au/Disclaimer_Copyright/Privacy_Statement
