EVP Support Service application

Unique ID

Submission Date

PART A: WORKER AND SUPPORT SERVICE DETAILS

Support Service Name

Support Service Category

Program Name

Worker Name

Worker Phone

Worker Email

Length of time involved with client

PART B : APPLICANT INFORMATION (person experiencing IPV)

First Name(Required)

Middle Name

Surname(Required)

date of birth(Required)

Phone number

Email

Residential Address * Only postcodes between 4849 - 4895 are eligible for the Cairns-based EVP trial.(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Considerations will be made for applicants planning to move from outside the region to our service area.

Details of Person Using Violence. (PUV)

Name

First Last

Date of Birth

PUV's current address (if known)

Did the client and PUV normally live together during the last three months?(Required)

Yes

No

PART C: EVP PACKAGE

It is important that you confirm the applicant has a safe way to receive the payments. This means that any payment cannot be intercepted or used by the Person Using Violence or others.

The applicant has confirmed that they have a safe way to receive EVP payment if approved.

Yes

No

EVP Payments	Options	How	Safe way to receive payments
Cash (Up to $1500)	Bank Transfer	Paid directly into client's bank account	Applicants BSB and Account Number
	Voucher	Applicants can spend funds online or at preferred shop	Safe email address, postal delivery, in person pickup
Goods and Services (Up to $3500)	Invoice payment	Payment to be made on receipt of invoice, quote or sales order	Applicant or support service to source quotes for goods and services
	Voucher	Applicant can purchase items online or at preferred shop	Safe email address, postal delivery, in person pickup

Applicant Bank Details

If a bank transfer has been selected as a applicants payment method (up to max $1500), please provide applicants bank details.

Confirm with applicant: Is this a joint account?
Is the account overdrawn?
Does the PUV have access to this account (email/internet/phone)?

Bank (financial institution)

Account name

* as per bank statement

BSB number

Account number

I confirm that I have sighted the applicants bank account and that these match their name.

Yes

No

Client current situation

Complete only support areas relevent to the applicant.
Complete each field for support area that the applicant is seeking EVP assistance with.

Step 1. - Please rate the applicants current status in that support area from 1-5.
Step 2. - Select the goal the client hopes to achieve for the support area.
Step 3. - Outline the purchases requested for the support area.
Step 4. - Include the amount required for that support area purchase.

Support area

Goal for support area
Please select one

Describe purchases required.

Amount required ($)

Please select a statement that best describes the applicants confidence in the support area.

Support area

Goal for support area
Please select one

Describe purchases required.

Amount required ($)

Please select a statement that best describes the applicants confidence in the support area.

Support area

Goal for support area
Please select one

Describe purchases required.

Amount required ($)

Please select a statement that best describes the applicants confidence in the support area.

Please indicate with EVP Client Services Officer if additional support areas are required.

Support Service application for Escaping Violence Payment

PART A: WORKER AND SUPPORT SERVICE DETAILS

EVP ELIGIBILITY CONFIRMATIONS

Client Consent, Privacy and Safety

PART B : APPLICANT INFORMATION (person experiencing IPV)

PART C: EVP PACKAGE

Applicant Bank Details

Client current situation

Please indicate with EVP Client Services Officer if additional support areas are required.

PART D: SUPPORTING DOCUMENTATION

PART E: WORKER DECLARATION

1300 663 411 info@raatsicc.org.au

CAIRNS

AURUKUN

PORMPURAAW

NPA

KOWANYAMA

LOCKHART RIVER