Payment difficulties and financial hardship form-Dragonfly Dance

Payment difficulties and financial hardship form

Please complete this form if you are experiencing circumstances that make it difficult for you to pay in accordance with previously agreed timeframes. We may be able to negotiate alternative payment arrangements. You may be required to provide evidence of your situation.

All information submitted verbally or in writing will be treated confidentially and in accordance with our Privacy and Confidentiality policies.

Please read our Payment Difficulties and Financial Hardship policy before completing the form.

First Name

Last Name

Please provide your payment difficulty or financial hardship and how this impacts on your ability to pay your membership fees.

Please indicate the type of assistance you are requesting from Dragonfly Dance

variation to payment methods and/or plans

reduction and/or waiver of fees and debts

extension to payment due dates

payments in instalments

opportunity to have fees or debts reduced in exchange for an inkind contribution from you ( a non

Additional information