Request for an absence application form

Complete this to seek approval if you intend to be away from your home for more than eight weeks. For absences shorter than eight weeks, please use this form to provide your contact details while you are away so we can contact you in case of emergencies.

Postcode

Tenancy
Reference Number: Tenant/s Name:
Address of property:

to

Details of absence

/	/

/	/

Dates you will be away: Why you will be away:
Note: Talk to staff your nearest Housing Service Centre about what supporting evidence you might need to provide

	Postcode		

Your contact details during your absence
Address:

Phone Number/s:

Email

Home

Work

Mobile

	
	
	Postcode		

Details of contact person to care for the property while you are away
Name:
Address:

Phone Number/s:

Email

Home

Work

Mobile

Privacy Notice: The Department of Housing is collecting your personal information so we may provide you with housing assistance. To assist you with your housing needs and services, your personal information may be disclosed to partner agencies, service providers, local governments and non-governmental agencies that now, or will, provide you with housing and/or support services. Unless authorised or required by law, your personal information will not be disclosed to any other third party without your consent. More information about the Department’s privacy obligations is  available on our website at www.housing.qld.gov.au.
Declaration
I/We (the tenant/s) hereby undertake to continue to satisfy all conditions of my/our State Tenancy Agreement, specifically the payment of rent (including two weeks in advance), completing the requirements of rent reviews that may be due during the absence period and ensuring the property is kept reasonably clean and tidy during the period of my/our absence. To the best of my knowledge, the information provided on and in conjunction with this form is true and correct.  I/We understand that it is an offence liable to a penalty under the Housing Act 2003 and a breach of my State Tenancy Agreement to knowingly provide false or misleading information to the Department of Housing.

Signature:
Date:

Signature

/	/

/	/

	

	

Date
Please return completed form to your nearest Housing Service Centre

Department of Housing
www.housing.qld.gov.au

PH042 (28/07/2023)