Further information regarding this Gift can be found by calling 1800 180 213 or at:
www.dhs.vic.gov.au/bushfireappeal
Email enquiries:
vicbushfireappealfund@dhs.vic.gov.au
Post
Victorian Bushfire Appeal Fund
GPO Box 4057
MELBOURNE VIC 3001
Fax
(03) 9092 1926
FOR THIS APPLICATION TO PROCEED YOU MUST SIGN THE STATUTORY DECLARATION AND
PRIVACY STATEMENT ON PAGE 4.
Applicant
Compassionate Financial Support Gift
Name:........................................................................................................................................................................
The fire affected address (if applicable):
..................................................................................................................................................................................
Your current address:
..................................................................................................................................................................................
Phone Number: ...................................................... Mobile Phone Number............................................................
Details of your family member/s deceased as a result of the 2009 Victorian bushfires.
First Name
Surname
Date of Birth
Relationship to you
Eligibility
This gift can be claimed by an eligible adult next of kin. The eligibility is limited to an immediate
family member and the same definitions for next of kin as per the Compassion and Bereavement
payment applied:
- Spouse or domestic partner
- Adult child (aged over 26 years)
- Parent
- Sibling
- Grandparent
If you are a bereaved child 26 or under and have received a Bereaved Children’s Payment, you
are not eligible for this gift as the Fund has provided for you under that gift.
Page 1 of 5
Current Situation
1. Are you aware of any other next of kin who may be eligible to share in this gift?
Yes
No
If Yes