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Energy Accounts Payment Assistance Referral Form

This form is for service providers to refer those who are having difficulty paying their electricity or gas bills. Once you complete the form, an assessment will be conducted to see whether the client fits our criteria. 

Privacy Statement

Linking Communities Network Ltd collects your personal information in order to provide assistance, support and advocacy to clients. This information will provide important statistics and help us find the most suitable service to suit your needs. Your personal information is protected under law and will not be passed on to anyone without your consent

Question for client
Do you provide consent for your personal information (name, sex, date of birth and suburb), the date you applied for assistance and the name of this service; to be available to other government and non-government homelessness services in NSW for one year after today’s date? Your personal information will be managed in accordance with the Information Privacy Act 2009.

Type of Referral

Priority

Gender

Is the Client Culturally and/or Linguistically Diverse?

Is an Interpreter Required?

Is the Client Aboriginal or Torres Strait Islander?

Type of Assistance Required

Existing Client of a Service Agency?

Please ensure all boxes are ticked in order to obtain assistance

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