Energy & Water Hardship Assistance Form

Instructions

Fill in this form to apply to ACAT for energy and water hardship assistance.
You must fill in the fields marked with an asterisk (*)
Please ensure you have contacted your utility about their hardship program before submitting this form.
After we receive your form, we will contact you within three business days to discuss your application.
If you have already been disconnected, or if you need help to fill in this form - please contact us on (02) 6207 1740.

1. Applicant details

Applicant's full name *

How do you pronounce your name? (optional)

Pronouns (optional)

Date of Birth *

Day Month Year

Street address number and name *

Suburb *

Postcode *

Is the postal address the same as the above address?

Postal address - Street number and name

Postal address - Suburb

Postal address - Postcode

Phone *

Email *

Confirm email *

I do NOT have an email address

Correct

Note: the preferred method for ACAT to contact the parties is by email.

Are you of Aboriginal or Torres Strait Islander origin? * We ask this question as there are support services we can refer you to that are available to persons of Aboriginal or Torres Strait Islander origin.

Yes
No
Prefer not to answer

Is somebody representing you and/or do you want someone to act on your behalf for this application? *

2. Representative's contact details

Representative's full name

How does the representative pronounce their name? (optional)

Representative's pronouns (optional)

What is the representative’s relationship to the applicant? (e.g. family or friend)

Representative's address

Representative's email

Confirm email

Representative's phone

Please fill out an Authority to Act for an Individual form if you want someone else to act on your behalf in relation to this application (unless this person is a lawyer).

I acknowledge that I will fill in and attach to this application an Authority to Act for an Individual form.

2. Is somebody representing you and/or do you want someone to act on your behalf for this application?

No - you do not need to complete this section.

3. Utility Information

Please provide details of any utility which is proposing to withdraw a service from you or has already withdrawn or disconnected the service (such as gas, electricity or water) by clicking the 'Add a utility' button.

Retailer *	Utility type (e.g. electricity, gas, water) *	Account Number	Amount Owing ($) *	Is the utility account in your name? *	If no, whose name is the account in?

Total utilities: 0

Add a utility

Are you part of the utility’s hardship program? *

Yes
No
I do not know

Which utility hardship program or programs are you a part of?

4. Disconnection of utility service

Reminder – if you have already been disconnected or are under threat of immediate disconnection, please complete this form and contact us on (02) 6207 1740.

Has your utility service been disconnected? *

Which utility service or services (gas, electricity, water) have been disconnected?

Are you at risk of disconnection?

Which utility service or services (gas, electricity, water) are likely to be disconnected and why?

5. Asking for reconnection and other interim orders

If your utility service has been disconnected, do you want a Tribunal Member to consider directing the utility to reconnect your utility service on a short-term basis, until the Tribunal considers what orders to make at your hearing? *

Yes
No
Not applicable

Note: if the Tribunal does this, it is called an interim order. An interim order will generally stay in place until the hearing, when the Tribunal can decide whether to change the interim order.

6. Decision on hardship after your hearing – final orders

What orders do you want the Tribunal to make at the hearing? * Tick the boxes below that apply to you:

An order directing the utility to reconnect, or not to disconnect, my utility service
An order discharging some or all of my debt
Other orders

Other orders

7. Housing, Occupation and Family

What is the ownership status of the home? *

Government Rental
Private Rental
Homeowner
Community Housing
Other

Other ownership

Do you have registered life support on the premises? *

Are there other people living in the home? *

Please add details of other people living in the home by clicking the 'Add a person' button.

Full name *	Relationship to you *	Age *

Other people living in the home: 0

Add a person

8. Fortnightly Income

Do you receive a pension or government allowance? *

What type of pension or government allowance do you receive?

How much is each of your pensions or government allowances?

Do you receive wages or other income? *

Please give details about what income you receive and how much you receive

9. Fortnightly Expenditure and Debt

Rent/mortgage, including insurance fees

Credit card repayments

Loan repayments

'Buy now, pay later' repayments

Fine repayments

Other

10. Availability

What dates are you not available to attend ACAT in the next 6 months? Include any days of the week or times of day you are not available.

Note: Whilst we aim to accommodate your availability, in some circumstances it may not be possible. If it is not possible, the Tribunal will contact you to inform you.

11. Accessibility

Do you need the Tribunal to provide (at our cost) the services of a language interpreter or hearing impairment interpreter?

Language and dialect you need interpreting

Would you like to request a reasonable adjustment be made? We may be able to adjust our services to make ACAT more accessible for you. Some adjustments that ACAT may be able to make include:
- Access to Hearing Augmentation System
- Access to wheelchair
- Escorting to tribunal room
- Sensory adjustments
- Communication adjustments
- Pre-hearing tour
- Regular breaks

Please describe the adjustment/s you are asking ACAT to make.

Important: this application may be given to the utility and any other party.

If you have any concerns or do not want to request an adjustment on this form, please call the Disability Liaison Officer on (02) 6205 0322 or email ACATAssistance@act.gov.au.

If we are unable to make an adjustment that you request, we will contact you to let you know.

Please note that your contact details and adjustment request may be passed on to the Disability Liaison Officer who may contact you for more details about how we can help.

There is more information about reasonable adjustments on the 'Accessibility' page.

12. Declaration

I make this Application under Part 12 of the Utilities Act 2000.

By submitting this application, I declare that:

The information provided in this application is true and correct to the best of my knowledge and belief.
I understand that a copy of this application and any attachments may be provided to the utility.

Please re-confirm your full name *

Supporting documents Please upload any documents e.g. Centrelink statements, medical certificates, health care card) that you wish to provide in support of your application. These can help to establish that you are suffering from financial hardship.
If you have a representative who is not a lawyer, please also fill in and attach the Authority to Act for an Individual form.
You can attach a maximum of 10 files and no file can be larger than 5MB.

If you are unable to upload these documents, please bring them to your first hearing.

Sorry, errors were detected.

Please correct the fields marked in red and then re-click the 'Next Page' button.

Glossary and terms

ACT Civil and Administrative TribunalA tribunal established under the ACT Civil and Administrative Tribunal Act 2008. It may also be referred to as ACAT or Tribunal.

Adjourn (or adjournment)To suspend or postpone a preliminary conference, mediation or hearing and reschedule it for a future date.

Administrative reviewACAT has jurisdiction to review some administrative decisions made by the ACT Government. Find out about Review of ACT Government decisions.

Alternative dispute resolution (ADR)Also known as dispute resolution. This is a way of resolving disputes without a formal hearing. It may involve a preliminary conference or mediation. ADR is used to help parties resolve cases by agreement.

AnorMeans ‘and another’. This term is generally used to name parties to proceedings when there is more than one applicant or respondent.

Appeal TribunalA tribunal constituted under section 81 of the ACT Civil and Administrative Tribunal 2008 to review a decision of the tribunal (not all ACAT decisions are appealable at ACAT – you may need to go to the Supreme Court).

AppellantThe individual or company that appeals an ACAT decision.

ApplicantThe individual or company that brings a case to ACAT, usually by making an application.

Authorising lawsA law that says an application (including referrals) may be made to ACAT. An authorising law may also set out the powers ACAT has in a case. Also see ‘jurisdiction’.

Calling a witnessA party or their representative will ‘call a witness’ at an ACAT hearing when they ask a witness to give evidence.

CaseAlso known as a matter, dispute, application or referral. Cases come to ACAT when ACAT has jurisdiction (power) to make a decision.

Cross-examinationThe process of asking a witness questions to test or check the evidence that the witness has given to ACAT.

DecisionWhat the tribunal decides or determines about an issue or a dispute. The tribunal may sometimes explain why in a statement of reasons.

Defined benefitsare the following benefits (see section 33 of the MAI Act):

income replacement benefits;
treatment and care benefits;
quality of life benefits;
death benefits;
funeral benefits.

Deliver a decisionAlso ‘handing down a decision’. This is giving a decision about an ACAT case. It may be done verbally or in writing (or both).

DirectionsInstructions that set out what each party must do (and when), often to prepare a case for hearing.

Directions hearingA short hearing where an ACAT Member or Registrar decides how to manage a case and what needs to be done before a hearing. Find out about directions hearings.

Ex parte orderAn order made by ACAT where one or more parties were not present.

Expert reportA written report from an expert that may be used as evidence.

Expert witnessA person with specialised knowledge based on their training, study or experience. An expert can give evidence at a hearing. Find out more about witness statements.

Final directions hearingSometimes ACAT will hold a final directions hearing prior to the final hearing of an application. The purpose is to make sure the case is ready to go to a hearing and give the parties a chance to ask questions about the hearing process.

GuardianA guardian is a person ACAT appoints to make personal decisions, about health, welfare and where a person lives, for a person who has impaired decision-making ability (the ‘protected person’).

Handed upGiving documents to an ACAT Member or Registrar in a hearing.

In chambersWhen ACAT considers something without holding a hearing.

Joined party (joined/joinder)A party who was not originally a party to the dispute but has later been added to the case.

JurisdictionACAT’s authority (power) to deal with, hear and decide applications (cases).

LeaveIf someone asks for leave, they are usually asking for permission to do something.

List (or listing)A schedule (or list) of cases to be heard at ACAT each day.

Listing noticeA letter or written document from ACAT that sets out when a conference, mediation or hearing is scheduled at ACAT.

ManagerA manager is a person ACAT appoints to make decisions, about property and money, for a person with impaired decision-making ability (the ‘protected person’).

MAI ActMotor Accident Injuries Act 2019 (ACT).

MediationA private meeting where parties discuss ways to resolve their dispute, with the help of an impartial mediator (who is also an ACAT Member or Registrar). It is held under section 35 of the ACT Civil and Administrative Tribunal Act 2008.

Non-publication and/or non-disclosure orderAlso called a ‘suppression order’. It is an order that requires certain information not to be published or disclosed. It is made under section 39 of the ACT Civil and Administrative Tribunal Act 2008. Find out about public hearings and confidentiality.

Notice to partiesA letter sent to the parties in a case that sets out the time, date and location for an ACAT conference, mediation or hearing.

Opening statementUsually means a statement made at the beginning of a hearing to outline the key points in the case. Sometimes parties are asked to give an opening statement at a mediation or preliminary conference.

OrderA direction or instruction of the tribunal that a person do a certain thing. The tribunal can make different types of orders depending on the case type and the tribunal’s powers in a case or dispute.

Originating applicationAn application that starts an ACAT case.

Party or partiesAn individual or company directly involved in an ACAT case, for example an applicant or respondent. Find out how to identify and name parties.

Preliminary conferenceA private meeting where parties discuss ways to resolve their dispute with the help of an ACAT Member or Registrar. See section 33 of the ACT Civil and Administrative Tribunal Act 2008. ACAT has different types of preliminary conferences.

Protected personA person who has impaired decision-making ability and about whom an application to ACAT may be made seeking orders under the Guardianship and Management of Property Act 1991 or the Power of Attorney Act 2006.

RegistryThe administrative section of ACAT that accepts documents lodged by parties, handles enquiries and provides support for case management.

Relevant insurerfor a motor accident, means the insurer under the Motor Accident Injuries Act 2019 (see section 34) of the motor vehicle considered to be at fault for the motor accident in the ACT.

RepresentativeA person who represents or advocates for an individual or company at a conference, mediation or hearing at ACAT. For example, a legal practitioner or an attorney appointed under a general power of attorney.

Reserved decisionWhen an ACAT Member or Registrar reserves a decision (at the end of a hearing), this means they will give their decision later, either verbally or in writing (sometimes both).

RespondentThe party (or parties) against whom orders or relief is sought.

Serve/serviceA person who can give evidence at a hearing. Find out about witness statements.

Short service orderAn order that authorises a shorter time for service (than the time otherwise required).

Significant occupational impact (SOI)Significant impact on an injured person’s ability to undertake employment.

Statement of reasonsA document that explains why ACAT made an order in a case. It sets out the law relied on by an ACAT Member or Registrar and explains how the law was applied to the facts of the case. You can request a written statement of reasons within 14 days after an order is made. Find out about statement of reasons.

StayAn order for a particular action (or decision) to be put on hold or suspended for a period of time.

SubmissionA document that sets out your side of a case or dispute and the relevant law. It is presented to ACAT either in writing, verbally or both. Find out about submissions.

SubpoenaRequires a person to appear at ACAT to give evidence or provide documents (or both). Find out about subpoenas.

Substituted service orderAn order that says how a party is to be served with an application or other documents related to the proceedings. In a civil dispute or a rental dispute, an applicant will need to consider asking for a substituted service order if they do not have a physical address for the respondent. Find out about lodging and serving documents.

WitnessA person who can give evidence at a hearing. Find out about witness statements.