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Your email address

How can we help you with your payment enquiry?

Payment Type: (optional)

First Name

Last Name

Date of Birth

E.G: 17/11/1986

Email address linked to your account:

Address 1

Address 2(optional)

State

Postcode

Contact Phone Number

Please include your area code where applicable. E.g 08 or 03

Item(s) location address

The address where the item(s) you rent from us live. E.G: 42 Smith Street, Gepps Cross SA 5094

Account/Application Number

Account Number

Your Centrelink Reference Number

I authorise Services Australia to make a Deduction of: $

Number must be between 10 ~ 999

Each fortnight from my:

Choose multiple for weekly payments

Please let us know where you would like the deduction to be taken from:(optional)

First payment date:

Pay this amount to ESSENTIAL APPLIANCE RENTALS PTY LTD - 555 071 352K for White Goods and Appliance Rentals

I agree that this deduction has no target amount and no end date

I give permission for ESSENTIAL APPLIANCE RENTALS PTY LTD to disclose my information to Services Australia for the purposes of checking my account number, billing number and amount I want to pay, and reconciling my payment Deduction details

Australian Privacy legislation protects your personal information.

I understand that I can change or cancel my Deduction at any time, and further information about Centrepay can be found online at www.servicesaustralia.gov.au/centrepay.

I acknowledge I have the authority to arrange this deduction as the customer listed above or their customer representative.

Please state the reason for your hardship request?

Is your situation permanent or temporary?

Please add a brief explanation of your Permanent or Temporary situation:

Have you applied for hardship with other creditors?(optional)

Name of other creditor(s) you have applied with & how much was the application for?

Fortnightly Wage 1:

The value entered must be a number containing a decimal. Example: 500.00

Fortnightly Wage 2:

The value entered must be a number containing a decimal. Example: 1200.00

Fortnightly Centrelink benefits which you receive as income:

The value entered must be a decimal number. EG: 485.50. Please enter 0.00 if this is not applicable to you.

Fortnightly Incoming Child Maintenance:

The value entered must be a decimal number. EG: 485.50. Please enter 0.00 if this is not applicable to you.

Other types of income & the associated fortnightly cost(s):(optional)

Please provide a brief description

Do you currently have a Mortgage, Rent or Board?

Mortgage, Rent or Board cost:

The value entered must be a decimal number. EG: 1250.00. Please enter 0.00 if this is not applicable to you.

Fornightly Council Rates:

The value entered must be a decimal number. EG: 1250.75. Please enter 0.00 if this is not applicable to you.

Fortnightly Gas / Electricity / Water:

Please enter a combined total. The value entered must be a number. EG: 350.00

Fortnightly Phone Costs:

The value entered must be a decimal number. EG: 85.00. Please enter 0.00 if this is not applicable to you

Fortnightly Vehicle Expenses (Registration / Insurance / Petrol):

Please enter a combined total or 0.00 if this is not applicable to you. The value entered must be a decimal number. EG: 1480.00

Fortnightly Insurance (Health/Life/House):

Please enter a combined total where required or 0.00 if this is not applicable to you. The value entered must be a decimal number. EG: 1850.00

Fortnightly Grocery spend:

The value entered must be a decimal number. EG: 485.00

Fortnightly Medical Expenses:

The value entered must be a decimal number. EG: 1575.00. Please enter 0.00 if this is not applicable to you.

Fortnightly Outgoing Child Maintenance:

The value entered must be a decimal number. EG: 547.50. Please enter 0.00 if this is not applicable to you.

Repayments to Walker Stores:

The value entered must be a decimal number. EG: 250.00. Please enter 0.00 if this is not applicable to you.

Fortnightly Payments to Other Creditors:

Please enter a combined total if you have payments with more than 1 other creditor or 0.00 if this is not applicable to you. The value entered must be a number. EG: 375.00

Please provide any additional information that you would like to add for consideration of your application.(optional)

IN SUBMITTING THIS APPLICATION FORM, YOU DECLARE THAT THE INFORMATION PROVIDED IS TRUE AND CORRECT.

Subject

Description

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