EAPA Enquiry Form

First Name: *

Last Name: *

Email Address: *

Contact No:

Date of Birth: *

Do you Consent to the above Privacy Policy for the purposes of this enquiry: * -- Please Select -- Yes No

Is your bill currently overdue: * -- Please Select -- Yes No

What was the due date of your bill?: *

Have you contacted your provider and asked for an extension: * -- Please Select -- Yes No

Who is your Gas / Electricity Provider:-- Please Select -- Energy Australia AGL Origin Energy Red Energy Alinta Other

Are you currently Experiencing Financial Hardship?: * -- Please Select -- Yes No

What is the nature of your financial crisis?: * -- Please Select -- Loss of Household Income Illness / Unexpected Medical Expense in Family A Family Crisis Unexpected Bills or Expenses A very High Gas / Electricity Account

Please upload supporting documentation for Financial Hardship i.e Bank Statement / Invoice / Receipt: *

Please attach a copy of the original Gas / Electricity Bill (in full): *

If you receive a Centrelink Payment please attach your latest Statement: *