Debt Review Request Form

Use this form to request a review of your debt with the Department of Housing. Return completed form and any supporting documentation to your nearest Housing Service Centre.

	
	Postcode:		
	Contact	Mobile		

Section 1 – Customer Details

Customer:
Address:

Home phone:
Email:
How would you prefer to be contacted? (You may choose more than one)

Mail
Section 2 – Debt Details

Phone

Mobile

Email

Type of debt
Debt account number:

Rent

Maintenance

Bond Loan

Bond Loan Plus
Debt amount $

Section 3 – Reasons for debt review request
Which aspect of the debt do you want reviewed?

Were there any circumstances present at the time the debt occurred, or is there any other relevant information, that you would like the department to consider in support of your request?

From the list below, please detail your current debt repayment arrangements:
Type of repayment	Yes	No	Amount of repayment	Frequency (weekly, monthly etc)	
Debt agreement	

Deed of repayment	

Easypay	

Payment card	

Other (please specify)	

Name:	Signature:	Date:
Name:	Signature:	Date:		
		
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.

Department of Housing
www.housing.qld.gov.au	PH117 (28/07/2023)