Notification Form

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					                                                                                                                                                                                                           Attachment A

                                                                                                                                         Australian Government Reference Number:
                                                                                                                                         (For administration use only)

  NDRRA Notification Form - Version #
  State/ Territory       ACT / NSW / VIC / TAS / QLD / NT / SA / WA                                                        Contact Details:
  (Please Circle)                                                                                                          Name:
                                                                                                                           Department:
                                                                                                                           Phone:
  Disaster Event Details:
  Name of Event:
  Type of Event:
  Date(s) Event Occurred:

NDRRA Assistance Available:
Please list all LGA’s affected by the event and indicate the assistance measures being provided. When complete please send to recovery@ag.gov.au.
Should a State/Territory activate additional assistance measures or LGA’s for this event, an updated Notification Form must be sent to Emergency Management Australia immediately.
Please attach a detailed description of all assistance measures available for this event. Include information such as the name of the assistance measure, a brief description of its purpose, amounts available, application
closing dates and details of the administering agency including contact information.
                                      Category A                                                                 Category B                                                                 Category C              Category D
                                                                                   Concess     Concess           Concess
                       Personal   Personal   Counter    Rest.                                                                        Interest Interest                               Clean Up Clean Up
                                                                                  Loans for   Loans for Concess Loans for  Freight                                         Community
                      Hardship      and      Disaster Essential                                                                        Rate     Rate   Grants to Grants to              and      and
                                                                         CDO        Small      Primary Loans for  Needy   Subsidies                                         Recovery                   (Please list)
                      Assistance Financial Operations Public                                                                        Subsidies Subsidies VNPB        NI               Recovery Recovery
                                                                                  Business    Producers VNPB Individuals     PP                                               Fund
        LGA             (PHD)    Counselling  (CDO)    Assets                                                                           SB       PP                                  Grant SB Grant PP
                                                                                    (SB)         (PP)              (NI)
                      3.2.2 a, b, c     3.2.2 g    3.2.2 f   3.3.1 a    3.3.1 c    3.3.2 a     3.3.2 a  3.3.2 b  3.3.2 b   3.3.2 c    3.3.2 d  3.3.2 d  3.3.2 e   3.3.2 e    3.4.1 a  3.4.1 b  3.4.1 c     3.5
                      State name
                      for measure

E.g. Dorset                            11/6/12     9/6/12    9/6/12     1/6/12




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Estimated cost             $              $          $          $         $          $           $         $           $         $         $          $         $          $           $          $          $           $

                                                                                                                                                                                             Total estimated cost        $

  I certify that the disaster event notified in this form meets the definition of an eligible disaster as specified in the Natural Disaster Relief and Recovery Arrangements Determination 2011.


  Name:                                                                                                        Date:
  Position:
  Signed:
  NOTE: This Notification Form must be certified by an appropriate officer of the State/Territory agency responsible for natural disaster relief and recovery.

				
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posted:10/1/2012
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