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How can we help you today?

Your email address

How can we help you with your payment enquiry?

First Name

Last Name

Date of Birth

E.G: 17/11/1986

Address 1

Address 2(optional)

State

Postcode

Contact Phone Number

Please include your area code where applicable. E.g 08 or 03

Contract Number

This will be a 5 or 6 digit ID number on your statements

Payment amount

Amount must be a whole number including cents E.G 125.00

Payment instalment amount:

Amount must be a whole number including cents E.G 125.00

Payment Frequency:

Date commencing:

Preferred payment date

The date you wish for this one-off payment to be processed on your card

I, the card holder, hereby authorise Walker Stores Pty Ltd 2 to deduct the above mentioned payment from the nominated credit card for the duration of my contract(optional)

I acknowledge that it is my responsibility to ensure that sufficient funds are available on the credit or debit card supplied for a minimum of 48 hours from the time of submission of this form.

If your declared payable amount is insufficient to service your contact and/or arrears, Walker Stored Pty Ltd 2 will notify you via email.

I confirm I have included any further details about this request in the description field below.

Reason for Hardship Request:

Is your current situation permanent or temporary? If temporary, please confirm the period you are seeking assistance for:

Please outline your other debts and remaining balances:

IE - Car Loan $350, Student Loan $265, Mobile Provider $130

Please add a brief explanation of your Permanent or Temporary situation:

Have you applied for hardship with other creditors?(optional)

Name of other creditor(s) you have applied with & how much was the application for?

Do you have dependants that you care for?(optional)

Yes/No

How many dependants and their ages?(optional)

For Example: 2 children aged 8 & 11

Your fortnightly wage:

The value entered must be a number containing a decimal. Example: 500.00

Second fortnightly wage (spouse/partner):

IE - Your partner or any additional income

Fortnightly Centrelink benefits received as income:

The value entered must be a decimal number. EG: 485.50. Please enter 0.00 if this is not applicable to you.

Fortnightly Child Maintenance - Incoming:

The value entered must be a decimal number. EG: 485.50. Please enter 0.00 if this is not applicable to you.

Other types of income & the associated fortnightly cost(s):(optional)

Please provide a brief description

Current living arrangements:

Fortnightly Mortgage, Rent or Board Cost:

The value entered must be a decimal number. EG: 1250.00. Please enter 0.00 if this is not applicable to you.

Fornightly Council Rates:

The value entered must be a decimal number. EG: 1250.75. Please enter 0.00 if this is not applicable to you.

Fortnightly Gas / Electricity / Water:

Please enter a combined total. The value entered must be a number. EG: 350.00

Fortnightly Phone Costs:

The value entered must be a decimal number. EG: 85.00. Please enter 0.00 if this is not applicable to you

Fortnightly Internet Costs:(optional)

Fortnightly Vehicle Expenses (Registration / Insurance / Petrol):

Please enter a combined total or 0.00 if this is not applicable to you. The value entered must be a decimal number. EG: 1480.00

Fortnightly Insurance (Health/Life/House):

Please enter a combined total where required or 0.00 if this is not applicable to you. The value entered must be a decimal number. EG: 1850.00

Fortnightly Grocery spend:

The value entered must be a decimal number. EG: 485.00

Fortnightly Medical Expenses:

The value entered must be a decimal number. EG: 1575.00. Please enter 0.00 if this is not applicable to you.

Fortnightly Subscription Services:(optional)

(Netflix/Spotify/Apple TV/Gym/Sport)

Fortnightly Outgoing Child Maintenance:

The value entered must be a decimal number. EG: 547.50. Please enter 0.00 if this is not applicable to you.

Fortnightly Contracted Payment Amount With Us:

The value entered must be a decimal number. EG: 250.00. Please enter 0.00 if this is not applicable to you.

Fortnightly Payments to Other Creditors:

Please enter a combined total if you have payments with more than 1 other creditor or 0.00 if this is not applicable to you. The value entered must be a number. EG: 375.00

Please provide any additional information that you would like to add for consideration of your application.(optional)

IN SUBMITTING THIS APPLICATION FORM, YOU DECLARE THAT THE INFORMATION PROVIDED IS TRUE AND CORRECT.

Preferred Contact Method

Would you prefer us to call you, or email you

Subject

Description

Please enter the details of your request. A member of our support staff will respond as soon as possible. If you have documents to provide, please attach below.

Attachments(optional)

Add file or drop files here