DAVID WILLIAMS FUND

51 Commercial Rd, South Yarra, 3141 Ph: 03 9863 0444

2024 Registration & Intake Form

(Incl. Application for Financial Assistance)

The David Williams Fund provides support to improve the well-being of the Victorian HIV community. The average application is approximately $125. Not all applications are approved as demand on the Fund is high. Eligibility: Clients must be experiencing financial hardship, HIV positive, resident in Victoria, receiving an income from Centrelink or DHHS, and have less than $5000 in their bank accounts/share/savings, etc. The fund does accept applications for: medical expenses, emergency food vouchers, some appliances, education costs and basic needs items. The fund cannot provide: legal fees, fines, personal loans, retrieval costs for pawned items, insurance, regular expenses, items already paid for, call/data charges on your telephone or credit card debt. The checklist at the end of this form will assist you to complete the application correctly. It may be to your advantage to access a community / social worker, to assist with your application. All applications for financial assistance must be lodged by 4.00 pm Friday to 51 Commercial Rd South Yarra 3141 or dwf@thorneharbour.org. All applicants are advised of the outcome by mail or, for pick up, on the following Thursday. As a publicly funded organisation we are bound by the Victorian privacy laws - the Information Privacy Act 2000 and the Health Records Act 2001 - as well as other laws which impose specific obligations on us in regards to handling information. Files are shredded if not used for seven years.
Legal Name*:
Preferred Name:
Address:
Postal add (if diff)
Date of Birth*:	Centrelink CRN:
Phone number:
Email address:
*Mandatory fields OR details via THH client file	
Case Worker Details (if applicable):
Name:	Phone:
Organisation:
If you do not want mail sent, please mark this box:	
Note: This may affect your ability to receive material aid by mail/delivery.

Verification of Health Status
Already uploaded to THH client file	
Attached to this Application	
Requested from Dr, will forward asap	
Verification of Centrelink / DHHS Benefits
Heathcare card already uploaded to THH client file	
Healthcare/SSRS card attached to this Application	
Income Statement attached to this Application	
Centrelink Authority attached to this Application	
Please call the client to arrange a verbal authority *You must make the client aware that we will call them	

General Statistical Information
The following information has been added to THH client file in its entirety	
What year were you diagnosed with HIV?

Gender:

Agender		Male/Man		Questioning	
Female/Woman		Non-binary		Unspecified	
Gender Queer		PNTS	

Pronouns:

Sex assigned at birth:

Male		Female		PNTS		Unknown/Not Stated		Transgender	

Intersex:

Yes		No		PNTS		Unknown/Not Stated	

Sexual Orientation:

Asexual		Lesbian		Queer	
Bisexual		Not Specified		Questioning	
Gay		Pansexual	
Heterosexual		PNTS	

Origins:

Country of birth	Ethnicity
Speaks English?	Yes		No		Language spoken at home

ATSI Status:

Aboriginal		Neither A nor TSI	
A and TSI		Not Stated	
Torres Strait Islander	

Residency status:

Citizen		Permanent Resident	
Migrant		Asylum Seeker	
Refugee		In Progress	
Unknown	

Financial Information
Income
What kind of Centrelink / DHHS Benefit do you receive?
How much do you receive per fortnight?	$
Do you have any other income? What Type?
How much do you receive per fortnight?	$
Total fortnightly income from all sources:	$
Accommodation
Boarding House		Independent Unit in Retirement Village		Public Hsg - Transitional	
Couch surfing		Paying Board		Supported Accommodation	
Crisis/Emergency		Permanent Housing		Temporary	
Homeless		Prison / Remand / Detention		Transitioning	
Home Owner		Private Rental		Other:
Hostel		Public Hsg – Permanent	
Are you in shared accommodation? If so, how many do you share with?
How much do you pay per month?

Financial Counselling
Do you have financial concerns about any of the following?
Infringements / Fines		Gambling (self or others)	
Assets at Risk		Credit Debt	
Emergency Relief		Legal Action	
Overdue Utilities		Telco Debts	
Outstanding Bills		Rental Goods	
Afterpay		Payday Loans	
Other – Please specify:
Please give a brief description of your financial Issues:
This box will expand as you type
Current Debts – Only required if you need our Financial Counsellor to assist with these debts
Credit Card	Total amount outstanding:	$
Monthly Payments:	$
Personal Loan	Total amount outstanding:	$
Monthly Payments:	$
Centrelink Loan	Total amount outstanding:	$
Fortnightly Payments:	$
Mortgage	Total amount outstanding:	$
Monthly Payments:	$
Other:	Total amount outstanding:	$
Monthly Payments:	$

Emergency Relief Application - item and payment information
Please note you may request multiple items but there is no guarantee that these will be granted. You must prioritise your requests as only one may be approved. The fund only provides payment to companies, not individuals.
Item:	Amount $:	Payable to:
1
2
3
eMail		Phone	
For pick up - call Positive Living Centre on 9863 0444 the following week to find out the outcome. If approved, food vouchers will be available after 1pm on the Thursday. If you are requesting one of the following, you do not need to attach quotes as the DWF has a supplier for these brand new products: Beds (queen mattress and base is assumed unless advised otherwise), electrical goods, direct from supplier deliveries. In all other cases, TWO quotes from different companies are required to accompany the application.
Other Funding Sources
Have other agencies been approached for assistance?	Yes		No	
Agency approached?
What was the outcome?
Are you requesting assistance with rent?	Yes		No	
If yes, which Housing Office did you apply to and what was the outcome?
If no, your Local Transitional Housing Office must be asked before putting in a DWF application. Please call 1800 825 955 to find your closest office.
Supporting Statement (required)
Please document below your current financial situation and degree of need, along with why you are in need of the item / service you are applying for assistance with.
This box will expand as you type
Changes since your last application
Have your income or expenses changed since your last application? If “yes” please document the changes below.
This box will expand as you type

Client Consent Statement
I authorise the DWF to seek verification if and where necessary to confirm any information provided in this application or any applications I may make in the future. I certify that all the information provided is true and correct. I agree that the DWF may share and exchange information in order to assist in resolving my financial difficulties with other agencies / companies directly involved, for the purpose of providing me with the best possible support to suit my circumstances. I understand that relevant information about me will only be shared when deemed necessary or to progress my case or application and consent to my name, address and phone number being given to the DWF supplier. I certify that all the information provided is correct and true.
Client signature:	Date:
If prepared by Case Worker on the Client’s behalf:
Case worker’s name:	Phone:
Signature:	Date:
Checklist:
If you haven’t attached the appropriate documentation your application will be delayed until the documentation has been provided All registration documents must be originials, not faxed or photocopies.
	I have attached verification of my HIV status, from my doctor. If you’d prefer, you can have your doctor email the verification directly to dwf@thorneharbour.org in confidence.
	I have attached a copy of my current Health Care Card (or there is a copy on Penelope).
	This is my first DWF application in 2024. I have attached a copy of my current Centrelink Income Statement or have signed an authority for DWF to do get one for me.
	I have attached quotes, if necessary, from two different suppliers.
	I have attached supporting documents such as support letters or outcomes from other organisations.
	For Rent applications – I have contacted my local transitional housing agent and have attached a copy of my lease agreement.
	I have attached a Tax Invoice or copy of my bill (to be considered, bills must be in your name), if appropriate.
	I understand that I may be asked to provide a supporting statement or evidence of financial hardship