OCCOM Financial Hardship Application

We understand Financial Hardship is different for everyone and we will work with you to identify the best solution for your individual circumstances. Applying for financial hardship assistance or entering into an arrangement is free of charge. You have the right to apply whenever you need it. We will prioritise keeping you connected. If you are seeking short term assistance or been impacted by domestic or family violence, you are not required to provide supporting documentation. Please complete this form and we will contact you within 5 business days with assistance options.

Personal Details

We need your details to verify that you are the account holder.

Customer Account Number / Registered Contact Details*

Have you ever applied for the Financial Hardship previously?*

Yes
No, this is my first time for this account.

Name*

First Last

Preferred contact method*

Home Phone
Email
Mobile

Home Phone Number*

Email Address*

Mobile Phone Number*

What's your main reason for requesting payment assistance?*

What type of relief are you seeking?*

Please tell us the amount involved, if known.

Please specify the duration of payment installments?*

Monthly
Bi-Weekly
Weekly

Could you kindly provide the amount payable by you?

(Note - Minimum amount should be $50 for weekly, $100 for Bi- weekly, $150 for monthly)

Please attach a document to support your Financial Hardship application. This may be:

Drop files here or

- Centrelink documentation (e.g. JobSeeker payment)
- Redundancy paperwork
- Medical record
- Bankruptcy notice/insolvency
- Reduced working hours payslip or employer's letter
- Business financial or sales records showing reduced turnover

Please add any comment you may wish to make regarding your situation.

*

I acknowledge that I am providing personal information to OCCOM Internet Pty Ltd and that I have read the Collection Notice.