Energy Accounts Payment Assistance Referral Form

Type of Referral Type of Referral Referral from Government Agency Referral from Community Organisation Self-referral Other / Internal Referral

Date of Initial Referral

Referring Agency / Organisation Name

Agency Worker Name

Agency Worker Phone

Agency Worker Email

Priority Priority Urgent Non urgent

Title / First Name / Last Name

Current Address

Town

Postcode

Phone

Does the Client have an Email Does the Client have an Email Yes No

Email Address

Date of Birth

Preferred Language (if other than English)

Gender Gender Female Male Transgender Non-binary

Is the Client Culturally and/or Linguistically Diverse? Is the Client Culturally and/or Linguistically Diverse? Yes No

Is an Interpreter Required? Is an Interpreter Required? Yes No

Which Language is the Interpreter Required for?

Is the Client Aboriginal or Torres Strait Islander? Is the Client Aboriginal or Torres Strait Islander? Yes No

Type of Assistance Required Type of Assistance Required Gas Electricity

Provide Comprehensive Description and Details of Sudden Emergency or Financial Crisis to Assist Referral

Existing Client of a Service Agency? Existing Client of a Service Agency? Yes No Unsure

What Agency?

Composition of Household (Which of the Following Best Describes the Composition of the Household) Composition of Household (Which of the Following Best Describes the Composition of the Household)Single PersonCouple with DependentsCouple – No DependentsSingle ParentOther

How Many People Currently Live in the Household?

Other – Please Specify

List Dependents Name/s and Date of Birth if Applicable

Please ensure all boxes are ticked in order to obtain assistance Please ensure all boxes are ticked in order to obtain assistance Client is the account holder Client can provide photo ID Client can provide copy of current bill ( a disconnection notice is NOT sufficient) – The electricity account must have a National Metering Identifier (NMI) or the gas account must have a Delivery Point Identifier (DPI)/Meter Installation Reference Number (MIRN) Client’s primary residence is in NSW Client is experiencing a sudden emergency or financial crisis and is having difficulty paying their current bill, or is at risk of disconnection or has been disconnected Client agrees to the EAPA privacy notice (agrees to information being provided to energy providers and NSW government)

Attach Photo ID Attach Photo ID

Attach Copy of Current Electricity or Gas Bill Attach Copy of Current Electricity or Gas Bill

This confirms that the client/applicant has been read the above privacy statement, indicated that they understand what it means and have given their verbal consent to the above **Consent is valid for one year from date of signing unless otherwise stated This confirms that the client/applicant has been read the above privacy statement, indicated that they understand what it means and have given their verbal consent to the above **Consent is valid for one year from date of signing unless otherwise stated I Consent