EVP Support Service application

Support Service application for Escaping Violence Payment 2025

Step 1 of 6

16%

Unique ID

PART A: CLIENT DETAILS

First Name(Required)

Middle Name

Surname(Required)

date of birth(Required)

Day

Month

Year

Phone number

Residential Address * Only postcodes between 4810 - 4895 are eligible for the Cairns-based EVP trial.(Required)

Street Address 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.

Cultural background(Required)

Gender(Required)

Sexuality(Required)

Citizenship(Required)

Country of Birth(Required)

Language Spoken(Required)

Specify language

Please specify if other than english

Is the applicant experiencing any of the following health concerns?

Chronic Health Illness

Mental Health

Physical/Diverse disability

Sensory/Speech disability

Other disability

None

Is the application experiencing homelessness?

If YES or AT RISK due to IPV, please describe the applicants housing situation.

What is the applicants living situation?

I the applicant currently employed?

What is the applicants main source of income?

PART B: EVP ELIGIBILITY CONFIRMATION

1. I can confirm that the applicant is over 18 years of age

Please upload confirmation of photo ID (front)

Max. file size: 256 MB.

Please upload confirmation of photo ID (back)

Max. file size: 256 MB.

2. I can confirm that the applicant is an Australia citizen / Permanent resident / Holder of a protected special

Please upload confirmed document (Medicare, passport, centerlink statement etc)

Max. file size: 256 MB.

3. Is the applicant the primary person experiencing or have they experienced Intimate Partner Violence (IPV) within the last 3 months(Required)

Name of person using violence

Name

First Last

Date of birth

Day

Month

Year

4. Does the applicant have a safe plan to leave or have they changed their living arrangements in the last 3 months due to intimate partner violence

5. Is currently experiencing financial stress due to the changed living arrangements or upcoming change as a result of IPV

6. The applicant has confirmed that they have not received EVP in the past 12 months

Length of time involved with client (Please outline the applicants intimate partner violence history, changed living circumstance in the last 3 months and the financial stress resulting from the changed living due to intimate partner violence)

Client Consent, Privacy and Safety

RAATSICC provides service delivery to individuals and are committed to protecting the privacy of personal information it collects, holds and administers in line with the Privacy Act 1988. RAATSICC collects and administers a range of personal information for the purpose of conducting our program activities and in obtaining funding to deliver services.

The Escaping Violence payment is a complimentary support and not a crisis payment.

Has the applicant consented to this application being submitted on their behalf?(Required)

Has the applicant consented to sharing their information with RAATSICC to process their EVP application?(Required)

Have you informed the applicant that their de-identified details will be collected and stored by RAATSICC EVP and the Department of Social Services?(Required)

Can you confirm that your service is supporting the applicant with ongoing case management, support and referrals?(Required)

Can you confirm that your service is supporting the applicant with appropriate DFV risk assessments and safety planning?(Required)

Can you confirm that you have informed the applicant they are able to withdraw this EVP application at any time?(Required)

Can you confirm that you will remain the contact for this EVP application if RAATSICC needs more information during the application process?(Required)

PART C: EVP SUPPORT PLAN

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.

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

Cash component up to $1500.

Amount

Payment type

Description of financial need

Confirm with applicant.

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

I confirm that this bank account belongs to the applicant and is safe to deposit the allocated funds

Yes

Upload 30 day Bank Statement (This must display applicants name, BSB and Account number )

Max. file size: 256 MB.

Goods and services up to $3500.00

Item 1.

Amount

Payment type

File

Max. file size: 256 MB.

File

Max. file size: 256 MB.

Description of financial need

Goal for support area

Please select one

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

Item 2.

Amount

Payment type

File

Max. file size: 256 MB.

File

Max. file size: 256 MB.

Description of financial need

Goal for support area

Please select one

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

Item 3.

Amount

Payment type

File

Max. file size: 256 MB.

File

Max. file size: 256 MB.

Description of financial need

Goal for support area

Please select one

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

PART D: SUPPORT SERVICE DETAILS AND SUPPORT WORKER DECLARATION

I declare to RAATSICC and the Department of Social Services that:

The information contained in this form is true and accurate.
The client meets the EVP Eligibility criteria.

Support service name(Required)

Program(Required)

Category(Required)

Support workers name(Required)

Phone(Required)

Email(Required)

Consent(Required)

I understand and agree to the declaration above.(Required)

Consent(Required)

I understand that RAATSICC EVP may be required to contact the applicant in regards to this EVP application.(Required)

Consent(Required)

I understand that my details will be collected and stored by RAATSICC EVP program case management system.(Required)

Consent(Required)

I acknowledge that giving false or misleading information to RAATSICC and the Department of Social Services via the EVP program is a serious offence.(Required)

Date

Day

Month

Year

Phone

This field is for validation purposes and should be left unchanged.

Support Service application for Escaping Violence Payment 2025

PART A: CLIENT DETAILS

PART B: EVP ELIGIBILITY CONFIRMATION

Name of person using violence

Client Consent, Privacy and Safety

PART C: EVP SUPPORT PLAN

Item 1.

Item 2.

Item 3.

PART D: SUPPORT SERVICE DETAILS AND SUPPORT WORKER DECLARATION

1300 663 411 info@raatsicc.org.au

CAIRNS

AURUKUN

PORMPURAAW

NPA

KOWANYAMA

LOCKHART RIVER