Applicant 1

Name*

Date of birth     

Country of birth

Main language spoken at home

Other language

Applicant 2

Name

Date of birth     

Country of birth

Main language spoken at home

Other language

If there are more than two applicants, fill in additional applicant's information in the text field provided below

Property and contact details

Current address*   
Postcode   

If applicable

New address   
Postcode   

Home phone

Mobile phone

Email

Reason for referral

Your tenancy must be at risk if you are currently housed

Tenancy matter
Homeless with offerArrearsNotice to Vacate issuedIn the process of evictionCouch surfingBreach NoticeLease breakingExiting crisis accommodationVCATImmediate noticeOther

Household type
SingleSingle parentCouple - no childrenCouple - with childrenCarer

Individual Income Renter 1

JobseekerDisability Support PensionParenting PaymentCarers PaymentEmployedOther
Income per week $

Individual Income Renter 2

JobseekerDisability Support PensionParenting PaymentCarers PaymentEmployedOther
Income per week $

If there are more than two applicants, fill in additional applicant's income information in the text field provided below

Other Client Information

Aboriginal or Torres Strait IslanderYesNo
Interpreter requiredYesNo
DisabilityYesNo
Literacy issuesYesNo
Diagnosed mental healthYesNo
Drug and alcohol issuesYesNo
OtherYesNo
Please list any current support workers

Current Tenancy Details – Current and New Rental Provider(property offer)

Agent/Rental Provider 

Agent/Rental Provider's Address                 

Agent/Rental Provider's Contact No.        

Lease start date   Lease end date

Currently on month-by-monthYesNo

Rent amount per week $

Bond amount $
DFFHTennant's own

Current Notice to Vacate  YesNo

Current VCAT hearing  YesNo

VCAT hearing details
Date  
Time  
Venue  

Warrant pendingYesNo

People who are or will be living in the property

Name/Date of birth/Relationship

Details about your situation and what support you are seeking

Provide as much information as possible

Amount requested and details

Amount $     support for  
Amount $    support for  

Required attachments

Tick all documents that are attached

Identification for all partiesRent ledgerNotice to VacateVCAT orderLetter of offerIncome statement/pay slips

Attach all documents

Note: Applications can take up to five working days to process. If all information has not been completed and documents provided this will delay the processing of your application

I, the applicant hereby give consent for the Private Rental Broker to make contact with my current Rental Provider/Real Estate/ New Rental Provider/New Real Estate for the purpose of conducting a rental reference check of my current/prior tenancies in order to confirm details provided in this application. I also give permission for Quantum Support Services to use the information collected about me for the purpose of evaluating Quantum's services and to provide data to Government funding Agencies. I give this permission with the understanding that my name will not be identified in relation for the use of this data.
This authority for releasing information will last for up to six months unless I expressly withdraw this permission

Signature    Date:  

Signature    Date:  

Note: Only one application per year for each family/relationship will be accepted