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Application for Assistance
PRIVACY ACT 2020:
This information requested on the "Application for Assistance" form is for the Princess Alexandra Medical Trust use only. It will be used to process your application assistance.
Note:
Your application cannot be processed until this form is filled in correctly and all applicable information required to accompany the application is received.
Note:
All Orthodontic applications will be reviewed by Wish For A Smile for potential funding through the Wish For A Smile Trust.
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Indicates required field
Applicant's Name
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Applicant's Email
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Applicant's Address
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Phone Number
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Mobile Phone Number
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Date of Birth
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Occupation
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IF APPLICANT A MINOR
Parent's Names
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Address
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Phone Number
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Mobile Phone Number
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Immediate Family (spouse, children or parents)
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ASSISTANCE REQUIRED
Type of medical assistance required
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GP
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Surgeon
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Cost: $
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How much can you contribute?
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Contribution regularity
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Up Front
Weekly
Fortnightly
Monthly
ADDITIONAL INFO
Would you commit to 20 hours voluntary work in the community?
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Yes
No
If yes, please explain:
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Community Services Card Holder Name
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Community Services Card Number
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Community Services Card Expiry Date
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Do you have Health Insurance?
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Yes
No
Details of Health Insurance
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Are you a beneficiary of, or do you have financial access to a Family Trust?
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Yes
No
IMPORTANT DOCUMENTS
Letter of support from your Doctor
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Max file size: 20MB
Full costing from surgeon
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Max file size: 20MB
Letter from Applicant outlining how this assistance will be beneficial
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Any other important files
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Max file size: 20MB
STATEMENT OF ASSETS & LIABILITIES
(N.B. If a minor parents details are required)
ASSETS
Cheque Account ($)
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Savings Account ($)
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KiwiSaver ($)
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Investments ($)
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House ($)
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Value of House Contents ($)
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Motor Vehicle ($)
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Other (Specify) ($)
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LIABILITIES
Overdraft ($)
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Loan ($)
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House Mortgage ($)
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Hire Purchases ($)
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Credit Card ($)
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Other (Specify) ($)
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STATEMENT OF INCOME & EXPENSES WEEKLY OR MONTHLY
(N.B. If a minor parents details are required)
INCOME
Salary/wages ($)
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Benefit ($)
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Child Support ($)
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Investments ($)
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- Interest ($)
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- Dividends ($)
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Regular Receipts ($)
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Other (Specify) ($)
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Total ($)
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EXPENSES
Rent ($)
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Mortgage ($)
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Rates ($)
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Insurance ($)
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Power/Gas ($)
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Phone/Mobile/Internet ($)
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Motor Vehicle ($)
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Food ($)
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Clothing ($)
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Subscriptions ($)
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Entertainment ($)
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Investments/Savings ($)
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Loan ($)
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Hire Purchases ($)
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Credit Card ($)
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Other ($)
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Total ($)
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Surplus/(Deficit) ($)
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INFORMATION TO ACCOMPANY THIS FORM
Make sure all included (unless otherwise stated):
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Letter of Support from your Doctor (not required for Orthodontics).
Letter/Report from Medical Specialist.
Full Costing from Medical Specialist.
Decline Letter from Public Health System.
Letter from Applicant outlining how this assistance will be beneficial.
Community Services Card (copy of front side).
3 Months of Bank Statements (if no Community Services Card).
If for a minor, and parents are seperated, both parents to complete an Application Form.
INFORMATION CORRECT
True and correct statement
*
I verify that all of the information in this online application is true and correct to the best of my knowledge.
Date
*
Submit
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