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Robe River Kuruma Charitable Trust Distribution Application Form
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Step
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Application Date
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Applicant's Name
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Date of birth
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Address
*
Address Line 1
City
State / Province / Region
Postal Code
Email
Phone
*
Who are you seeking assitance for (if not applicant)?
i.e Child's name
Date of birth
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i.e Child's date of birth
Relationship to applicant
i.e 'Child'
Fund you are applying for
*
Medical Assistance
Lore and Culture
Education
Senior Hardship
Funeral
Medical Assistance
*
Category A - Critical and Ongoing $20,000 max per year
Category B - General Medical $3,000 (>50) $5,000 (<50) max per year
Lore and Culture
*
RRK Boy going through Lore $6,000 max per family of boy
Activities on RRK Country $800 for lore and cultural max per year
NAIDOC activities $200 max per year
Education
*
Primary/Childcare $1,000 max per year
Secondary $7,500 max per year
Tertiary/university $10,000 max per year
Computer $1,500 max every 3 years
Senior Hardship
*
Quality of Living $7,000 Whitegoods, utilities, groceries max per year
Fuel $500 max per year
Next
Details of assistance required
*
Item/assistance requested
*
Amount
*
Supplier
*
Quote/invoice
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You can upload up to 3 files.
Item/assistance requested (#2)
Amount (#2)
Supplier (#2)
Quote/invoice (#2)
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You can upload up to 3 files.
Item/assistance requested (#3)
Amount (#3)
Supplier (#3)
Quote/invoice (#3)
Click or drag files to this area to upload.
You can upload up to 3 files.
Food assistance
Coles
Woolworths
(if required as part of your application)
Other
Fuel assistance
BP
Shell
(if required as part of your application)
Have you sought or received help from anywhere else?
*
Yes
No
PATS
If yes, where?
Amount?
Are quotes/invoices for items requested attached?
*
Yes
No
Supporting Evidence
Click or drag files to this area to upload.
You can upload up to 3 files.
Supporting Evidence Checklist
*
Education: Proof of enrolment attached
Education: Proof of 75% attendance attached
Senior Hardship: Proof of hardship attached (income tested Government assistance such as Centrelink or Pension, or earnings of less than $60,000 single income or $90,000 married or De Facto).
Lore and Culture Assistance: Cultural endorsement received by RRKAC
Medical Assistance: Have you approached PATS for assistance?
Medical Assistance: Written evidence and documentation from a doctor/medical specialist/health professional attached
Next
Please tick each point to confirm you have read and understand the declaration you are signing.
*
All information and details on this form are accurate and true.
Declaration #2
*
I understand that all information contained within and attached to this application may be shared with RRKAC and KML. I understand
Declaration #3
*
I understand that it is my responsibility to ensure that my contact details are correct and that I am contactable by RRKAC. I am aware that if I am not contactable for a period of seven days from the date of applying for assistance, my application will be withdrawn and not processed. I will be required to make a new application for further assistance.
Declaration #4
*
I understand that the bills/items to be paid will be paid direct to the supplier only.
Declaration #5
*
I understand that if I have reached the maximum annual limit for this funding type, my application will be rejected.
Declaration #6
*
I will not sell, swap or exchange any items, products, fuel, food, gift cards or equipment purchased by the trust directly or by me through gift cards for personal gain.
Declaration #7
*
I understand that I (or any person who assisted me to complete the form) may be contacted regarding my application if further information is required for assessment and prioritisation purposes.
Declaration #8
*
Should my application be successful I am fully responsible for the repairs and maintenance of any goods or the utilisation of services once acquired.
Declaration #9
*
If my application is successful, I will inform RRKAC of any chance in my financial circumstances.
Declaration #10
*
I agree that if I am found misusing KML Charitable Trust Funds in any way that I may be disqualified from accessing further funding from the Charitable Truast for a period of up to 12 months.
Declaration #11
*
I agree to ALL terms and requirements of the KML Charitable Trust Fund policies, including the Members Support Program Policy.
Declaration #12
*
I am not claiming benefits from another source for this expense.
Declaration #13
*
I understand that my application will be processed by RRKAC within FIVE (5) business days once all required supporting documentation has been received. I am aware that any attempts made by me to bypass any steps in the process will be seen as a deliberate breach of process and will disqualify me from accessing further funding from the Charitable Trust for a period of up to 12 months.
Declaration #14
*
I confirm I am a registered beneficiary of the Kuruma Marthudunera Limited Trust
Applicant Signature
*
Clear Signature
Date
*
If you received help to complete this form please supply details below:
Phone
Signature
Clear Signature
Please confirm your preferred method of contact for all RRKAC communications and notices, this will be updated on your profile for future mail-outs
*
Email
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