Hardship Review Board enquiry

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You will need to attach documentary evidence to support your answers in this application. Evidence may include:

copies of your payslips, Centrelink statements or other evidence of your income
copies of your bank account, credit union or building society statements for the last three months
evidence of any loans or credit cards you have (please redact the card details)
evidence of any large debts, such as energy, gas or water bills
report from a doctor or psychologist explaining any medical condition
report from a case worker, social worker or other professional confirming domestic problems
police report or court documents to confirm domestic violence
rental statements, lease agreement or rate notice where applicable
details to be provided for the person you would like to give authority to act on your behalf

Provide as much supporting documentation as you can to help the Board understand your situation. Have this ready before you start your application. You cannot save a partially completed application.

Providing a false or deliberately misleading statement may lead to prosecution under Section 307A of the Crimes Act 1900.

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Note: All fields marked with asterisk () are mandatory. To submit your application, you must attach all supporting documentation listed in your application.

Application type

I am applying:

I am applying

In relation to debts in my name On behalf of someone else

Has the person you are applying on behalf of already given you authority to act with Revenue NSW?

Yes No

If we are unable to find that authority, your application will not be processed until it has been provided.

Please have the person you are applying on behalf of:

contact Revenue NSW to provide you with authority, or
complete this form and include it when you restart the application.

The debt is in the name of:

The debt is in the name of

A company, organisation, business, trust, or other legal entity A natural person or persons

The Hardship Review Board can only review debts in the name of a natural person. Contact Revenue NSW to discuss your options.

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Your information

Your own information (not the person you are applying on behalf of)

Person or company

Choose person or company: percomp

title

Title: title

first name

First name: firstname

last name

Last name: lastName

company name

Business name: businessName

AbnnAcn

ABN/ACN: abnAcn

contact title

Title: contactTitle

contact first

Contact first name: contactFirst

contact last

Contact last name: contactLast

position

Position: position

Date of birth

Date of birth:

Email:

Disclaimer: Information you supply on this form may be provided to third parties with your consent or as required or permitted by law. Revenue NSW will correct or update your personal information at your request. Read more about privacy at www.revenue.nsw.gov.au

Organisation name (if applicable):

What is your relationship to the person you are applying on behalf of?:

Phone number

Phone number:

Address

Please enter residential address only

Country

Country:country list

Address line 1

Address line 1:Address line 1

Address line 2

Address line 2:

Suburb/State/Postcode

Suburb/State/Postcode:Suburb/State/Postcode

Overseas address

Address:overseasResAddr

Mailing address

The same as the address above

Mailing country

Country:country list

Mailing address 1

Address line 1:Street address line 1

Mailing address 2

Address line 2:

Mailing Suburb/State/Postcode

Suburb/State/Postcode:Suburb/State/Postcode

Mailing overseas address

Address:overseasResAddr

Preferred contact method:

Preferred contact

Email Mail Phone

If we are unable to contact you via telephone, we will respond to your request by email. Please ensure your contact details are correct.

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Your information

Person or company

Choose person or company: percomp

title

Title: title

first name

First name: firstname

last name

Last name: lastName

company name

Business name: businessName

AbnnAcn

ABN/ACN: abnAcn

contact title

Title: contactTitle

contact first

Contact first name: contactFirst

contact last

Contact last name: contactLast

position

Position: position

Date of birth

Date of birth:

Email:

Disclaimer: By providing your email address to our office you are consenting to receive notifications and other information via email, this may include but is not limited to arrears notifications, alerts of new fines, due dates and payment information. You can change these preferences at any time by contacting us.

Phone number

Phone number:

Address

Please enter residential address only

Country

Country:country list

Address line 1

Address line 1:Address line 1

Address line 2

Address line 2:

Suburb/State/Postcode

Suburb/State/Postcode:Suburb/State/Postcode

Overseas address

Address:overseasResAddr

Mailing address

The same as the address above

Mailing country

Country:country list

Mailing address 1

Address line 1:Street address line 1

Mailing address 2

Address line 2:

Mailing Suburb/State/Postcode

Suburb/State/Postcode:Suburb/State/Postcode

Mailing overseas address

Address:overseasResAddr

Preferred contact method:

Preferred contact

Email Mail Phone

If we are unable to contact you via telephone, we will respond to your request by email. Please ensure your contact details are correct.

Would you like to add an authority to act on your behalf?:

Add Authority to Act

Yes No

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Authorised person's information

Information about the person you are authorising to act on your behalf

Person or company

Choose person or company: percomp

title

Title: title

first name

First name: firstname

last name

Last name: lastName

company name

Business name: businessName

AbnnAcn

ABN/ACN: abnAcn

contact title

Title: contactTitle

contact first

Contact first name: contactFirst

contact last

Contact last name: contactLast

position

Position: position

Date of birth

Date of birth:

Email:

Organisation name (if applicable):

Phone number

Phone number:

Address

Please enter residential address only

Country

Country:country list

Address line 1

Address line 1:Address line 1

Address line 2

Address line 2:

Suburb/State/Postcode

Suburb/State/Postcode:Suburb/State/Postcode

Overseas address

Address:overseasResAddr

Mailing address

The same as the address above

Mailing country

Country:country list

Mailing address 1

Address line 1:Street address line 1

Mailing address 2

Address line 2:

Mailing Suburb/State/Postcode

Suburb/State/Postcode:Suburb/State/Postcode

Mailing overseas address

Address:overseasResAddr

Preferred contact method:

Preferred contact

Email Mail Phone

If we are unable to contact you via telephone, we will respond to your request by email. Please ensure your contact details are correct.

Extent of Authorisation

Authorised for

Authorised for:

All matters A specific matter

Authorisation Period

Authorisation Period:

Ongoing Temporary

Reference No

Authorisation end date:

Privacy Statement:
Your personal information is being collected by Revenue NSW (RNSW), authorised by the Fines Act 1996, or the State Debt Recovery Act 2018, or the Taxation Administration Act 1996.
We collect your personal information to manage your appeal to the Hardship Revenue Board. RNSW takes the protection and privacy of your personal information seriously by handling personal information in a responsible manner and in accordance with the NSW Privacy Laws; Privacy and Personal Information Protection Act 1998 and Health Records and Information Privacy Act 2002.
Your personal information may be disclosed to:

Service NSW
Revenue NSW's contracted printing and document capture service providers
The issuing authority responsible for the matter
The person you nominate. Note: disclosure of your name only in this instance

We may also disclose your information to other bodies as permitted or required by law.
Please refer to the Revenue NSW Privacy Policy for information on how to access or amend your personal information, or to make a privacy complaint.

Authority to Act Acknowledgement

I acknowledge the information I have provided is true and correct. This authority will remain ongoing. If there are updates to the information supplied on this form I will notify Revenue NSW.

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Product

Products are:

Products are

Fines Land Tax Payroll Tax Gaming Machine Tax Duties Fees Grants Levies

What did Revenue NSW do?:

What did Revenue NSW do?

Declined to write off the debt Wrote off less than I asked for Declined my payment plan application Approved a payment plan with higher instalments than I offered Declined to reduce the payments on my payment plan Cancelled my payment plan Declined my work and development order application Declined to change my work and development order Cancelled my work and development order Declined to revoke my overdue fees Revoked some of my overdue fees, but not all of them None of the above

What effort have you made to pay your debt?

What effort have you made to pay your debt?:

How will payment of the debt cause you serious hardship?

How will payment of the debt cause you serious hardship?:

What do you want the Hardship Review Board to do?

What do you want the Hardship Review Board to do?:

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Financial position - Income

What is your main source of income?:

What is your main source of income?

Employed Self-employed Receiving a government benefit Receiving other income Not receiving any income

Employer:

Self-employment details (name of business):

Benefit type:

Description of other income:

How are you being financially supported?:

Other people in your household

Name

Name:

Date of birth

Date of birth:

Relationship

Relationship:

Name

Name:

Date of birth

Date of birth:

Relationship

Relationship:

Name

Name:

Date of birth

Date of birth:

Relationship

Relationship:

Name

Name:

Date of birth

Date of birth:

Relationship

Relationship:

Income after tax - fortnightly

column 1	You	Your partner (if applicable)	last column
Net wage / salary (after tax)	netWageYou	netWagePartner	empty column
Sole trader / self employed income	soleTraderYou	soleTraderPartner	empty column
Centrelink benefit including Family Tax benefit A&B	centrelinkFamBenefitYou	centrelinkFamBenefitPartner	empty column
Business / partnership income	busPartnerIncomeYou	busPartnerIncomePartner	empty column
Child support	childSupportYou	childSupportPartner	empty column
Rental / board income	rentalIncomeYou	rentalIncomePartner	empty column
Workers compensation, sickness or accident insurance payments	workersCompYou	workersCompPartner	empty column
Income from any shares	incomeFromSharesYou	incomeFromSharesPartner	empty column
Other income	otherIncomeYou	otherIncomePartner	empty column
TOTAL INCOME	$0.00 totalIncomeYou	$0.00 totalIncomePartner	empty column
empty column	GRAND TOTAL	$0.00 totalIncome	empty column

At least one field required.

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Financial position - Expenses

Expenses - fortnightly

empty column	Amount paid	Owed to?	Balance remaining
Mortgage repayments	mortgageAmt	mortgageOwedTo	mortgageBalance
Rent or board	rentBondAmt	rentBondOwedTo	rentBondBalance
Car loan / lease	carLoanAmt	carLoanOwedTo	carLoanBalance
Food / groceries	foodGroceriesAmt	foodGroceriesOwedTo	foodGroceriesBalance
Electricity / gas	electricityGasAmt	electricityGasOwedTo	electricityGasBalance
Phone	phoneAmt	phoneOwedTo	phoneBalance
Clothing	clothingAmt	clothingOwedTo	clothingBalance
Rates (council and water)	ratesAmt	ratesOwedTo	ratesBalance
Fares / fuel	faresFuelAmt	faresFuelOwedTo	faresFuelBalance
Motor vehicle expenses	motorVehicleExpenseAmt	motorVehicleExpenseOwedTo	motorVehicleExpBalance
Insurance	insuranceAmt	insuranceOwedTo	insuranceBalance
Voluntary superannuation contributions	voluntatySuperAmt	voluntatySuperOwedTo	voluntatySuperBalance
Health fund contributions	healthFundAmt	healthFundOwedTo	healthFundbalance
Medical / medication expenses	medicalExpenseAmt	medicalExpenseOwedTo	medicalExpBalance
Personal loan repayments	loanDebtRepaymentAmt	loanDebtRepaymentOwedTo	loanDebtBalance
Credit card repayments	creditcardRepaymentAmt	creditcardRepaymentOwedTo	creditcardBalance
Store cards	storeCardsAmt	storeCardsOwedTo	storeCardsBalance
Deferred purchases e.g Zippay, Afterpay	deferredPurchaseAmt	deferredPurchaseOwedTo	deferredPurchaseBalance
Taxation or other government debt repayments	taxGovtDebtAmt	taxGovtDebtOwedTo	taxGovtDebtBalance
Centrelink loan / debt repayments	clinkDebtRepaymentAmt	clinkDebtRepaymentOwedTo	clinkDebtBalance
School / education expenses	schoolExpensesAmt	schoolExpensesOwedTo	schoolExpensesBalance
Child support	childSupportAmt	childSupportOwedTo	childSupporBalance
Entertainment	entertainmentAmt	entertainmentOwedTo	entertainmentBalance
Child care	childcareAmt	childcareOwedTo	childcareBalance
Other expenses	otherExpenseAmt	otherExpenseOwedTo	otherExpenseBalance
FORTNIGHTLY TOTAL EXPENSES	$0.00 totalExpenditure	empty column	$0.00 totalExpenditure

At least one field required.

If you declared 'other expenses' or if any expenses are unusually large, please provide a further explanation here:

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Financial position - Assets

Assets (what you own)

empty column	Asset particulars (e.g address)	Market value or total $
House and land (primary residence)	houseLandDetails	houseLandVal
Other real estate (provide address)	otherRealEstateDetails	otherRealEstateval
Motor vehicle (make / model)	motorVehicleDetails	motorVehicleVal
2nd motor vehicle (make / model)	motorVehicleDetails2	motorVehicleVal2
Caravan / trailer	caravanTrailerDetails	caravanTrailerVal
Boats	boatDetails	boatVal
Household furniture	houseFurnitureDetails	houseFurnitureVal
Electrical goods	electricalGoodsDetails	electricalGoodsVal
Shares (details)	sharesDetails	sharesVal
Superannuation balance	superannuationDetails	superannuationVal
Investments (details)	investmentDetails	investmentVal
Assets held outside Australia	assetsOutAUDetails	assetsOutAUVal
Other assets	otherAssetsDetails	otherAssetsVal
TOTAL ASSETS	empty column	$0.00 totalAssets

At least one field required.

If you declared 'other assets' or if you wish to make a statement about any significant assets listed above, please provide a further explanation here:

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Other information - personal, medical or domestic circumstances

Tell us about any circumstances you would like the board to consider:

Additional information and supporting documentation

Please attach any supporting documents, including:

copies of your payslips, Centrelink statements or other evidence of your income
copies of your bank account, credit union or building society statements for the last three months
evidence of any loans or credit cards you have (please redact the card details)
evidence of any large debts, such as energy, gas or water bills
report from a doctor or psychologist explaining any medical condition
report from a case worker, social worker or other professional confirming domestic problems
police report or court documents to confirm domestic violence
rental statements, lease agreement or rate notice where applicable.

Acceptable file types are: .zip; doc; docx; xls; xlsx; jpg; jpeg; png; gif; tif; tiff; pdf and txt with a maximum file size of 5 MB and total upload size of 20 MB per submission.

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Privacy statement

The information in this form is required for the Hardship Review Board to consider your case. Revenue NSW performs the function of secretary to the Hardship Review Board. Your application will be received by Revenue NSW. It will then be shared with the Hardship Review Board.

The information may be provided to third parties with your consent or as required by law. You may correct or update personal information by contacting Revenue NSW.

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You are not eligible to apply to the Hardship Review Board. Contact Revenue NSW to discuss your options.