FINANCIAL DETAILS

MBPH FOUNDATION GRANTS
MILDURA BASE PUBLIC HOSPITAL FOUNDATION
FINANCIAL DETAILS
PLEASE COMPLETE THE FINANCIAL CIRCUMSTANCES FORM ON THE FOLLOWING PAGE AND UPLOAD OR EMAIL WITH ALL OF YOUR OTHER APPLICATION SUPPORTIVE DOCUMENTS.
Applicant's Statement of Current Financial Position:
Contact Details
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
ASSETS
Bank accounts, savings
Investments
Real estate
Furniture, household goods etc.
Motor vehicles
Superannuation benefits
Other assets
Bank overdraft
Bank loans
Personal debts
Hire purchase
Credit cards
Store cards
Income tax
Other liabilities
TOTAL (Assets less Liabilities):
Applicant's Statement of Income and Outgoings (Monthly basis)
Salary, wages
Interest and dividends
Other (please specify)
Government benefits (please list, i.e. carers payments etc)
Rent, mortgage
Utilities
Housekeeping, food etc
Transport
Medical
Income tax
School
Other living expenses
TOTAL (income less outgoings):

I declare that the Statement of current Financial Position and Statement of Income and

Outgoings set out above correctly details my financial position as at the date of completing this Application Form.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Contact Details