Financial Hardship Assistance IGD Financial Hardship Assistance IGD Please complete this form and we will contact you with assistance options. Order Number Personal Details We need your details to verify that you are the account holder. Customer Account Number * Have you applied for Financial Hardship with us previously? * Yes No, this is my first time for this account. Are you seeking assistance on other accounts with us? * Yes No Account Holder's Name * Contact Email Address on Your IGD Account * Best Contact Number * What's your preferred contact method? * Email Phone Account Holder's Date of Birth * Financial Hardship Are you experiencing Financial Hardship due to COVID-19? * Yes No What's the reason related to COVID-19? * Business loss Loss of job or income Illness (diagnosed with COVID-19) Other What type of relief are you seeking? * Temporary postponement or deferral of payments Payment arrangement for unpaid or future amounts Early Termination without penalty Other What is the reason of your Financial Hardship? * Lost of employment of you or a family member Illness, physical incapacity, hospitalisation or mental illness of you or a family member Family breakdown A death in the family Being a victim of domestic or family violence Natural Disaster Business Loss Other (please indicate) Please tell us the amount involved, if known. $ Please tell us the amount involved, if known. Please indicate any finacial assistance you currently receive from the government * Jobkeeper Jobseeker Parenting Payment Not currently receiving any benefit Other Please attach a document to support your financial Hardship Application. This may be: * - Centrelink documentation (e.g. Jobseeker payment) - Medical record - Bankruptcy notice/insolvency - Reduced working hours payslip or employer's letter - Business financial or sales records showing reduced turnover Please attach a document to support your financial Hardship Application. This may be: Please add any comment you may wish to make regarding your situation. * Maximum of 500 characters All personal information collected are handled in accordance to our Collection Notice * All personal information collected are handled in accordance to our Collection Notice I acknowledge that I am providing personal information to IGD Computer Solutions Pty Ltd and that I have read the Collection Notice