BLM Financial Hardship Assistance Application

BLM Financial Hardship Assistance Application

Use this form to apply for support in meeting your commitments to recharge your Better Life Mobile service as a result of financial hardship

1. Who is completing this form?

I am completing this form:

If you are completing this form on behalf of someone else

Your relationship to the customer
Do you have authority to act on the customers behalf?
If you do not already have authority, we may need to confirm this before discussing account details with you. We can still receive the request and take steps to protect the customer’s service while we assess what is needed.

2. Customer Details

Please provide the details of the customer applying for financial hardship assistance
Customer full name
Customer full name
First Name
Last Name

3. Safe contact preferences

We want to contact you in a way that is safe and suitable for your circumstances.
What is the safest way to contact you?
Please select all that apply
Are there any contact methods we should not use?
What is the best time to contact you?
Please select all that apply
Is your request urgent because you may lose access to an important service?

4. Your payment assistance application

You only need to tell us what you are comfortable sharing. You do not need to provide sensitive personal information unless you choose to.
Why are you asking for payment assistance?
Select any that apply

5. How long do you think you need help for?

If you need help for up to 3 billing cycles, this is treated as short-term assistance. You do not need to provide evidence for short-term assistance. If you need help for more than 3 billing cycles, we may ask for supporting information if it is reasonably necessary to assess your request. We will not ask for evidence if your situation involves family or domestic violence
I think I need payment assistance for:

6. What help would you like from Better Life Mobile?

Please select the options that may help you
Do you currently have payment assistance or a payment arrangement with Better Life Mobile?

7. What can you afford to pay?

We ask this so we can consider an arrangement that is realistic for you
Can you make a payment now?
Can you make ongoing payments?
How often can you pay this amount?
Would you like payments aligned to when you receive income, wages, pension, benefits or other support payments?

8. Your service needs

We will take into consideration your circumstances and the importance of keeping you connected.
Do you rely on your Better Life Mobile service for any of the following?
Please select all that apply

9. Supporting information

You do not need to upload documents to apply. You do not need to provide evidence if you are asking for short-term assistance for up to 3 recharge cycles or your situation involves family or domestic violence. For longer-term assistance, we may ask for supporting information if it is reasonably necessary to assess your request. We will only ask for information that is relevant to your application.
Would you like to upload any supporting documents now?

Maximum file size: 268.44MB

Would you prefer to provide supporting information another way?
If yes, how would you like to provide it?

10. Anything else we should know?

Your financial hardship situation might arise from domestic or family violence, an illness or other sensitive circumstances. Perhaps that means you can’t easily take phone calls, but you can call us back if we text you. Or perhaps it’s best that we email you. If there’s anything that you want us to know in order to deal with your application safely and sensitively, please let us know below.
This is optional. You can use this space to explain what outcome you are hoping for, any risks we should be aware of, or anything you want us to consider.

11. Privacy and consent

Better Life Mobile will use the information you provide to assess your request for payment assistance, contact you about your application, manage any agreed payment assistance arrangement, help keep you connected where appropriate, meet our legal and regulatory obligations and respond to complaints, disputes or enquiries about your application. Some information you provide may be sensitive, such as information about health, family or domestic violence, financial circumstances or personal hardship. You do not need to provide sensitive information unless you choose to or unless we explain why it is reasonably needed for your application. We will handle your information in accordance with our Privacy Policy and applicable law. We will take reasonable steps to protect your information from misuse, interference, loss, unauthorised access, modification or disclosure.
Acknowledgements & Authorities