Financial & Clerical Assistance Request (Form-1068)

FINANCIAL AND CLERICAL ASSISTANCE REQUEST (Form-1068)

Additional Fees and Charges Apply
Participant's Details
Name:

First NameLast Name
Date:

DayMonthYear
Date
Which of the following services would you like Australian Quality Care to assist you with:
Would you like Australian Quality care to store any personal property (e.g., Pension Cards, Translink Cards) in a secure and safe place?
By selecting yes, you consent and approve Australian Quality Care to store the following belongs in a safe place. You understand that you can ask for these at any point and Australian Quality Care is obliged to hand them over.

Should you wish to revoke this agreement, I must let Australian Quality Care know in writing that I will take full responsibility for all my property.
Please indicate which property you would like Australian Quality Care to keep safe:
Signature of Resident

*Or signature of person acting on authority under Guardianship Administration Act 2000 or Powers of Attorney Act 1998 for the person named above, OR an Informal Decision Maker (must have an Informal Decision Maker Details Form-1066 signed) for the person named above.
Name

First NameLast Name
Signature
Date

DayMonthYear
Date
In the presence of (Witness)
Name

First NameLast Name
Signature
Date

DayMonthYear
Date
Should be Empty:

FINANCIAL AND CLERICAL ASSISTANCE REQUEST (Form-1068)