Apply For Assistance STA Form

APPLICATION FOR ASSISTANCE

STA FUND ADMINISTRATED BY THE ACTORS BENEVOLENT FUND OF NSW

www.actorsbenevolentfund.org.au

Our Rules of Association allow us to:

Raise and accumulate funds in order to provide financial and/or other assistance to members of the entertainment profession as defined in the Guidelines. Financial assistance may be provided in cases of hardship due to injury, illness, accident or disability for the member for such period and in such manner as the Management Committee deems fit.

Please note: We are only able to assist those residing in NSW. Other States have their own Benevolent Funds, or similar. Information given in this document is confidential.

First Name *

Last Name *

Email *

Address *

Suburb *

State *

Postcode *

Country

Date of Birth *

Phone *

MEAA Membership Number (If Applicable)

Amount Requested *

Please supply a brief summary of the reason you require assistance *

Your annual income from: Salary *

Your annual income from: Pension *

Your annual income from: Benefits *

Your annual income from: Investments *

Your annual income from: Other *

Total Annual Income *

Value of your: Savings *

Value of your: Property *

Value of your: Car *

Value of your: Shares/Managed Funds *

Value of your: Other assets *

TOTAL ASSET VALUE *

Your monthly expenses: Rent/Mortgage *

Your monthly expenses: Food *

Your monthly expenses: Car *

Your monthly expenses: Utilities *

Your monthly expenses: General Expenses *

Your monthly expenses: Debt Repayments *

Your monthly expenses: Other expenses *

TOTAL MONTHLY EXPENSES *

Do you live with a partner?

I have dependents

To help us assess your application, please describe to us your illness, disability, accident and/or any other detail relating to the reasons for your request for assistance. *

I understand that the details in this application are confidential and will never be made public. The Actors Benevolent Fund of NSW on behalf of the Actors Benevolent Fund reserves the right to make discreet enquiries about the information provided. *

I also understand that, should I be granted assistance, I will inform the Actors Benevolent Fund of any changes to my current circumstances which may affect my eligibility for assistance. I also undertake to provide the Fund with any updated information as may be requested from time to time. *

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+61 2 9333 0915

info@actorsbenevolentfund.org.au

245 Chalmers Street, Redfern, NSW, 2016

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