General Claim Request

Section 1 of 3

Applicant details

First name

Last name

Email address

ABN

Include spaces, e.g: 12 312 312 312

BP number

Numbers only, beginning with 2 (e.g. 2545678)

Case number

Which program are you submitting invoices for?

Is this your last payment?

YesNo

Program ID

Section 2 of 3

Please note: Claims are paid exclusive of GST. Please take this into account when submitting a claim request.

You can add multiple invoices by clicking the Add another invoice link at the bottom of the box.

Invoice

Amount

$

Does the amount entered include GST?

YesNo

Upload tax invoice

Please ensure file sizes are 2.5MB or less

Date of invoice

Tax invoice reference number

Supplier name

Supplier ABN

Include spaces, e.g: 12 312 312 312

Description of works

OTHER PRODUCT RESOURCE CODE ID

SCSG PRODUCT RESOURCE CODE ID

IncGSTAmount

FinalAmount

ExclGSTAmount

FINAL PRODUCT RESOURCE CODE ID

Repaired Date

Proof of payment

Please upload proof of payment documents here. Proof of payment can consist of receipts, bank statements, internet banking payment receipts, etc.

Proof of payment documents

Please ensure file sizes are 2.5MB or less

Supporting documentation

Please upload any other relevant documentation/information

Supporting documentation

Please ensure file sizes are 2.5MB or less

Step 3 of 3

You are no longer able to update your bank account details via this form. If you would like to update your bank account for payments please contact the RAA by calling 1800 678 593 or email rural.assist@raa.nsw.gov.au.

General Statement & Privacy

General Statement *

Any person who knowingly and with intent to defraud the Authority or another person, files an application for assistance containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent act, which is a crime under the Crimes Act 1900 and subjects the person to criminal penalties.

Privacy Collection Notice *

The information in this application is provided voluntarily and is being collected by the NSW Rural Assistance Authority (‘the Authority) for purposes related to the administration of the scheme of assistance under which you have applied, including the assessment of the effectiveness of the scheme. This may involve disclosing the information in this application to a third party engaged by the Authority or to either State or Commonwealth government agencies. The Authority will supply you with details of those parties that the Authority has disclosed information to if you apply to the Authority in writing. Information regarding this application may also be discussed and exchanged by the Authority with the authorised nominated contact persons listed by you as part of your application.

The Authority agrees to take all reasonable measures to ensure that the personal information collected by the Authority is stored securely.

You may access or correct your personal information by contacting the Authority by telephone on 1800 678 593 (toll free) or by writing to: Manager Administration, NSW Rural Assistance Authority, Locked Bag 23, ORANGE, NSW, 2800. Calls to "1800" numbers from your home phone are free. Calls from public phones and mobiles may be timed and attract charges.

I agree *

Thank you for your claim.