ApplicAtion Form

Small Business Bushfire Support Grant

Rural Finance po Box 1313 Bendigo Central 3552

Rural Finance – A Brand used by Bendigo and Adelaide Bank Ltd ABN 11 068 049 178 AFSL/Australian Credit Licence 237879

P 1800 260 425 F (03) 5441 8901 governmentservices@ruralfinance.com.au www.ruralfinance.com.au

1. Program Summary

The Small Business Bushfire Support Grants of $10,000 are available for small businesses and primary producers in East Gippsland, Towong, Alpine, Alpine Resorts (including Falls Creek, Mount Hotham, Mount Buller and Mount Stirling), Indigo, Wangaratta, Mansfield and Wellington Shires who have experienced significant income loss as a result of the 2019/20 summer bushfires. Please refer to the program Guidelines for eligibility criteria at ruralfinance.com.au before completing this form. Applications close 31 December 2020.

2. Applicant Detailsname:

Your role in the business (eg. Director, Manager, owner-operator, sole trader etc):

telephone: Mobile: Email:

Have you or another business owner previously applied for the grant? Yes No

If yes, was it for an eligible separate business (as defined in the guidelines for this grant program)? Yes No

3. Business DetailsBusiness / trading name:

Business legal / registered name:

Business Type (eg. retail, bakery, accommodation, professional services etc):

Australian Business Number (ABN):

Business Street Address:

Postal Address (if different from above):

Shire:

Is the business a public company, charitable business (charitable business means a business that operates for public benefit and does not operate to make a profit) or body corporate under the Owners Corporation Act 2006?

Yes No

Number of full-time equivalent employees:

If the business has 20 or more full-time equivalent employees, is your annual turnover less than $50 million? N/A Yes No

4. Bank Account DetailsAccount Name in full (as it appears on your statement)

Bank: BSB: Account No:

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5. Reason For ClaimingWas this small business located and operating under the provided ABN in one of the defined disaster areas (ie. Alpine, East Gippsland, Towong, Wellington, Indigo, Mansfield or Wangaratta) when the eligible disaster occurred? a) If no, does your small business operate part-time or on some regular basis within a defined disaster area?

Yes

Yes

No

No

Has your small business suffered a decline in revenue of 40% or more in a relevant three month period (compared to a relevant three month period the previous year) as a result of the 2019/2020 bushfires, and not due to the impact of COVID-19? If no, please apply under Exceptional Circumstances in Section 6 below.

Yes No

6. Exceptional Circumstances (Only complete if your business did not suffer a decline in revenue of 40%)

To apply under exceptional circumstances (refer to section 4.2 in the guidelines) please outline how your business has been significantly impacted by the eligible disaster below:

7. Privacy ConsentI/We authorise Rural Finance a brand used by Bendigo and Adelaide Bank Ltd ABN 11 068 049 178 (“Rural Finance”), for the purposes specified in Rural Finance’s Privacy Statement, to obtain from and/or disclose to my/our accountant and other advisors, credit providers, insurers, rating authorities, government agencies providing me/us with support including Centrelink and other debtors, creditors, authorities and institutions named in data supplied to or otherwise obtained by Rural Finance in connection with this Application, any consumer or commercial information about my/our expenditure and my/our business including my/our assets, liabilities, income and/or expenditure.

I/We acknowledge that:-- Rural Finance’s Privacy Statement is available on its website

and at its offices;- I/We can gain access to personal information (as defined in the

Information Privacy Act 2000 (Vic)) which Rural Finance holdsabout me/us in certain circumstances specified by legislation.

- I/We acknowledge that failing to provide some or all of theinformation which Rural Finance requests about me/us mayresult in this Application not being processed or approved.

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8. Consent and Signed DeclarationI certify that:

a. I have not, as far as I am aware, omitted any information that would have a bearing on the consideration of my application,and I acknowledge that I may be required to provide evidence of statements made in this application.

b. The Statements set out in this application are true and correct in every particular.c. I understand this grant is for small businesses which have had a significant decline in revenue as a result of the 2019-20 bushfires.d. I understand that my application may be subject to audit and upon audit I will be required to produce:

• evidence of decline in revenue associated with the eligible disaster, for example bank statements, evidence of cancellationsof bookings, invoices issued or business activity statements compared to a similar three month period the year before

• evidence to support the location of the small business• evidence to support bushfire damage or impact within defined disaster areas (for example photographic evidence of damage

or other impacts) for businesses located outside of the defined disaster area• evidence of the number of full time equivalent staff and annual turnover (for example, payment summaries)

e. I understand that the use of personal information provided for the purposes of this application complies with the limitations under theInformation Privacy Act 2000 (Vic).

I understand that if the application is found to be untrue or misleading the matter may be referred to law enforcement and penalties may apply.

I agree to this certification

Full name: Signature: Date:

Note: It is a criminal offence to provide false or misleading information to the Government.

9. How to Apply:Please submit your completed application form and supporting documents to Rural Finance by 31 December 2020 via: Post: Rural Finance, PO Box 1313, Bendigo Central 3552 Email: governmentservices@ruralfinance.com.au Fax: 5441 8901

10. Supporting DocumentsPlease attach the following to support your application: (Please tick)

Evidence of business location (eg. rates notice/lease agreement, utility bill)

Proof of identity (eg. Australian drivers licence, Medicare card or Australian passport)

Evidence of decline in revenue (eg. financial records, profit and loss, BAS statements)

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