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					APPLICATION FOR

SMALL BUSINESS
EXCEPTIONAL CIRCUMSTANCES
INTEREST RATE SUBSIDY



CHECK LIST                                                                                                     
Before you lodge your application check that you have:

           1)     Completed the Application including a description of your Small Business.

           2)     Attached copies of the last 3 years Balance Sheets and Financial Statements of your
                  Small Business. (These include Profit and Loss Statements, and Depreciation
                  schedules), and any associated entities or partnerships.

           3)     Attached copies of the last 3 years Individual Taxation Returns and a current listing
                  of all Assets and Liabilities held by each:
                  - Individual Director(s)/Shareholder(s) of all companies
                  - Individual members of partnerships/Firm & Family Trusts

           4)     Complete list of personal Assets and Liabilities for all Directors, Partners,
                  Shareholders etc of the business.

           5)     Attach a Monthly Cash Flow Budget for the next 12 months. A manual cash flow is
                  attached but you may use of your own computerised schedule if available.

           6)     Attach a Lender’s Certificate for each lending institution.

           7)     Attach a brief outline of the negative effects the drought has had on your business.

           8)     Provide a break up of sales for the last 12 months (including cash sales).

           9)     Signed the Recipient Created Tax Invoice Agreement and Declaration, item 14 in this
                  application.




 NSW Rural Assistance Authority    Application 11                                                 V: 2 10/07
1.     APPLICANT(S) DETAILS
 FULL NAME(S)                                                     Position ( Director,          Date of Birth
                                                                  Trustee, Partner etc)
                                                                                                      /       /
                                                                                                      /       /
                                                                                                      /       /
                                                                                                      /       /

 Business and / or Trading Name:
 ABN:

 Business Address

                                                                                           Postcode
 Phone:                            Mobile:                                  Fax:
 E-mail:

 Postal Address [If different from business address]

                                                                                           Postcode

 Home Address [If different to business & postal address]

                                                                                           Postcode
 Phone:                             Mobile                                 Fax
 E-mail:

2.     BUSINESS DETAILS
 Please provide a brief description of your business.




 How many years have you operated the current small business?                                                Years

 How many employees does your business have?                Permanent                     (Full Time Equivalent)
 (Please note a full time employee is one working at        Casual                        (Full Time Equivalent)
  least 35 hours per week)                                  TOTAL                         (Full Time Equivalent)
 List the Rural Lands Protection Board area(s) in
 which you conduct the majority of your business
 or your towns location.

 Is at least 70% of your normal business turnover derived from the provision of
 goods and services from your business direct to farm businesses in Exceptional                   Yes         No
 Circumstances declared areas?

 If Yes, what type of goods            Irrigation services
 and / or Services does your           Transport services
 business provide to farmers?          Consultants, agents, advisory or financial services (including
                                       accountancy and bookkeeping)
                                       Contractors e.g. Harvesting, fencing, shearing etc.
                                       Suppliers – farm machinery, equipment, seed, fertilizer and
                                       other suppliers
                                       Other services and suppliers (please specify)

NSW Rural Assistance Authority    Application 11        2                                             V: 2.0 10/07
 If No, indicate the type of              Retail Goods – includes General Stores, Newsagents, Clothing
 small business.                          Stores, Butchers, Hardware and Electrical Stores etc
                                          Retail Services – includes Post Office, Hairdressers, Smash
                                          Repairs and Mechanics
                                          Accommodation Services – includes Hotels, Caravan parks
                                          Hospitality – includes Restaurants, Cafes, Take Away
                                          Rural Services – E.g. Horse Trainers, Saddlery, Horse Breeders etc
                                          and sub-contractors to the rural industry.
                                          Manufacturing / Wholesale
                                          Construction – Decorator, Builder, Plumber, Electrician
                                          Financial Services
                                          Non Rural Transport



 Is your business significantly dependant upon farmers or farming clients?                      Yes / No



 If Yes, please describe how your
 business is dependant upon
 farmers / farming families?




 Advise the last 12 months income         - Goods and/or services for farming
 derived from:                              activities/farming families              $                     %
                                          - Other income                             $                     %
                                          - TOTAL INCOME                             $                     %

 Provide evidence of the above (attach documents – Break up of last 12 months sales to farm
 businesses/farming clients and Business Activity Statements (BAS) to reconcile).

 Details of any Farm Property presently held (if more than 1 please attach a list)
 Property Name
 Registered Proprietor/s                                                           Area (ha)
 Date Purchased               Current Market Value $                     Amount Owing $

 Have you purchased any capital items since 7 November 2006?                                    Yes / No
 eg: Property, plant and equipment etc.
 If yes, please provide details (attach list).
      Capital item purchased                     Date purchased                   Purchase price




3.      FINANCIAL STATEMENTS
 Do you wish to have the attached copies of your financial statements returned to   Yes       No
 you after your application has been assessed? (Please tick either ‘Yes’ or ‘No’)
 NOTE: Unless you select ‘Yes’ your financial statements will be destroyed by shredding or other
 means of secure disposal.



NSW Rural Assistance Authority     Application 11       3                                       V: 2.0 10/07
4.       COMMITMENT SCHEDULE
Enter information on Small Business debts including overdraft, term loans, lease, hire purchase, private/family loans etc.
Lender or                              Type               Purpose               Interest                Limit            Present
Credit provider                                                                   Rate                                   Balance




                                                                          TOTAL
                                                                          BORROWINGS



5.       STATEMENT OF FINANCIAL POSITION OF APPLICANT(S)
If individual partners or directors hold assets or liabilities that are not shown below please provide a separate statement.
                            WHOLE DOLLARS ONLY – DO NOT USE CENTS
 Liabilities (Show present Small      $     Assets (Estimated fair market value)                                               $
                  Business debts)

 Bank (from above)                                              Real estate – Residential (Home)
                                                                              Investment
                                                                              Business Premises
 Other lenders (from above)                                                   Rural Property
                                                                              Other

 Hire purchase/leasing (from above)                             Plant & machinery (please attach a list)

                                                                Motor vehicles (please attach a list)

 Accounts Payable      30 days                                  Accounts receivable – 30 days
                       60 days                                                        60 days
                       90 days & over                                                 90 days

 Wages, salaries & entitlements owing                           Stock on hand
 to employees
                                                                Work in progress
 Taxes
                                                                Cash on hand
 Home loan
                                                                Investments (eg. Debentures/shares)
 Personal debts (include store/credit
 cards)                                                         Life Policies
                                                                (Estimated Surrender Value)
 Other liabilities (please detail)                              Superannuation (Current estimated value)

                                                                Livestock
                                                                Other Assets (Show details)

 TOTAL                                                          TOTAL



6.       BANK ACCOUNT DETAILS
Please provide bank account details for payment of the subsidy. Payment may be made to the lender or the applicant.

 Account Name:                                                  Bank Name:
 BSB No:                                                        Account No:


NSW Rural Assistance Authority           Application 11             4                                               V: 2.0 10/07
    7. HIRE PURCHASES ARRANGEMENTS
This certificate is required by the NSW Rural Assistance Authority to assist in the provision of interest subsidy support under the Exceptional Circumstances provisions of the Rural Adjustment
Scheme.

                                                                                 Hire Purchase Accounts
          Loan       Equipment                            Interest       Repayment       Frequency of repayment,          Number of       Deferments     Balloon Payment at end
                                        Financier
          Type        Details                              Rate           amounts          eg monthly, annually         Repayments left                       of agreement




NSW Rural Assistance Authority
LMB 23
ORANGE NSW 2800

Telephone 1800 678 593
Facsimile 02 6391 3098
E-mail rural.assist@raa.nsw.gov.au
Internet www.raa.nsw.gov.au



NSW Rural Assistance Authority       Application 11                                            5         V: 2.0 10/07
    8. LEASE ARRANGEMENTS
This certificate is required by the NSW Rural Assistance Authority to assist in the provision of interest subsidy support under the Exceptional Circumstances provisions of the Rural Adjustment
Scheme.

                                                                                      Lease Accounts
          Loan       Equipment                            Interest       Repayment       Frequency of repayment,          Number of       Deferments     Balloon Payment at end
                                        Financier
          Type        Details                              Rate           amounts          eg monthly, annually         Repayments left                       of agreement




NSW Rural Assistance Authority
LMB 23
ORANGE NSW 2800

Telephone 1800 678 593
Facsimile 02 6391 3098
E-mail rural.assist@raa.nsw.gov.au
Internet www.raa.nsw.gov.au


NSW Rural Assistance Authority       Application 11                                            6         V: 2.0 10/07
      9. MONTHLY CASH FLOW (Your own computerised schedule is preferable)
 Please provide your monthly cash flow for the next 12months.
 Income                         Past 12 Months                                     Totals
Opening Stock
Closing Stock
Cash Sales
Trade Debtors
GST Received
Insurance Recoveries
Other Income

Total Income
 Expenditure
Accountant/Solicitor
Bank Charges
Insurance
Electricity & Telephone
Fuel, Oil
Lease Rentals
Rates, land taxes
Repairs/Maintenance
Vehicle Regist/Insure
Wages
Trade Creditors
Stock Purchases
GST Paid
Personal Expenses
Drawings
Education / Life Ins / Super.
Income Tax
Debt Repayment
Principal
Interest
Lease/HP instalments
Capital Expenses
Equipment purchase
Other

Total Expenditure




 NSW Rural Assistance Authority             Application 11      7   V: 2.0 10/07
10.      PRIVACY STATEMENT

The information in this application is provided voluntarily and is being collected by the NSW Rural
Assistance 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 contractors engaged by the Authority or to government
agencies including the Commonwealth Department of Agriculture, Fisheries and Forestry. Information
regarding your application may also be discussed and exchanged with the nominated contact persons listed
by you in your application.

Not providing the information requested in this application or providing false or misleading or incomplete
information may impact on the ability of the Authority to accurately assess your application.

The NSW Rural Assistance Authority agrees to take all reasonable measures to ensure that the personal
information collected by it 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.

11.      THIRD PARTY INFORMATION

 Please provide contact details for the following if appropriate.

                                                              Accountant
Firm
Contact
                     Phone                               Fax                E-mail
                                                                    Bank
Name
Contact
                     Phone                               Fax                E-mail
                                                               Financier
Name
Contact
                     Phone                               Fax                E-mail
                                                               Financier
Name
Contact
                     Phone                               Fax                E-mail
                                                         Rural Counsellor
Firm
Contact
                     Phone                               Fax                E-mail



12.      HOW DID YOU FIND OUT ABOUT THIS ASSISTANCE?
  Rural Assistance Authority               Accountant       Government Department     Papers
  Financial Counsellor                     Bank             Industry Organisation     Radio
  Television                               Farm Family Gatherings        Other



NSW Rural Assistance Authority             Application 11            8                          V: 2.0 10/07
13.           RECIPIENT CREATED TAX INVOICE and DECLARATION
All applicants are required to complete the following Agreement (see below point 14) to, among other things,
enable the Authority to arrange payment of the relevant Small Business Exceptional Circumstances Interest
Rate Subsidy (SBECIRS) if the application is successful.

14.           RECIPIENT CREATED TAX INVOICE AGREEMENT and
              DECLARATION
The RCTI component of this agreement is made in accordance with A New Tax System (Goods and Service Tax) Act 1999 Classes
of Recipient Created Tax Invoice Determination (No. 1) 2000
between
NSW Rural Assistance Authority (ABN 17 283 358 394) having its head office at 161 Kite Street, Orange, New South Wales,
2800 (the “Recipient” and “Authority”)
and
………………………………………………………………………………………………………                                ……………………………………………………………………………………………………..
……………………………………………………………………………………………………...                              ……………………………………………………………………………………………………..
(Name of Applicant(s))   (the “Supplier” and “Applicant”)                  (Address of Applicant(s))


…………………………………………………………..
(ABN)


together referred to as the Parties.

In this agreement:                                                                       time this agreement is executed and the Recipient
                                                                                         will notify the Supplier if the Recipient ceases to be
“Adjustment Event”, “Adjustment Note”, “Taxable                                          registered;
Supply” have the meaning given to them in the GST Law.                          4.       will issue to the Supplier an Adjustment Note in
“DAFF” means the Commonwealth Department of                                              relation to Adjustment Events within twenty eight
Agriculture, Fisheries and Forestry.                                                     (28) days of the Adjustment Event to which the
“Determination”       means      Determination     of   the                              Adjustment Note relates;
Commissioner of Taxation set out as schedule 1 to Goods                         5.       will reasonably comply with its obligations under
and Services Tax Ruling GSTR 2000/10 entitled “Goods                                     the taxation laws.
and services tax: recipient created tax invoices”.
“SBECIRS” means Small Business Exceptional                                      The Supplier:
Circumstances Interest Rate Subsidy.                                            1. will not issue tax invoices in respect of SBECIRS;
“GST” means goods and services tax.                                             2. acknowledges that the Supplier is registered for GST
“GST Law” means A New Tax System (Goods and Services                                 at the time this agreement is executed and will
Tax) Act 1999.                                                                       immediately notify the Recipient if the Supplier
“RCTI” means a recipient created tax invoice that satisfies                          ceases to be registered.
the requirements of the GST Law and associated rulings and
determinations, including the Determination.                                    B. DECLARATION

A. RCTI                                                                         The Applicant:
The Parties agree that:                                                         1. declares that the information provided in the
                                                                                     SBECIRS application is true and correct at the time of
The Recipient:                                                                       lodgement; and
1. may, within twenty eight (28) days of making or                              2. undertakes to contact the Authority immediately if the
     determining the value of the Taxable Supply that is                             information provided in the SBECIRS application
     related to the SBECIRS, issue an RCTI in respect of                             changes; and
     any SBECIRS to the Supplier in respect of that supply                      3. agrees to the terms and conditions set out in the
     (whether paid in one or more amounts);                                          SBECIRS application including the privacy statement;
2. must not issue a document that would otherwise be an                              and
     RCTI, on or after the date when the Recipient or the                       4. agrees to participate in any follow up survey if
     Supplier has failed to comply with any requirement                              requested by the Authority or DAFF to do so.
     of this agreement;
3. acknowledges that it is registered for GST at the

Signed as an agreement by the Parties to the terms and conditions set out herein.

___________________                 __________________          __________________                     __________________
Signature of Applicant              Signature of Applicant      Signature of Applicant                 Signature of Applicant
Date: ___/___/___                   Date: ___/___/___           Date: ___/___/___                      Date: ___/___/___


Signed for and on behalf of the NSW Rural Assistance Authority (ABN 17 283 358 394): __________________
Date: ___/___/___
NSW Rural Assistance Authority                 Application 11          9                                                        V: 2.0 10/07
                                 Applications should be returned to

                                     NSW Rural Assistance Authority
                                   Locked Bag 23, ORANGE NSW 2800


                                                   Contact details

                                   161 Kite Street, ORANGE NSW 2800
                                         Telephone 02 6391 3000
                                           Freecall 1800 678 593
                                         Facsimilie 02 6391 3098
                                     Email rural.assist@raa.nsw.gov.au




NSW Rural Assistance Authority    Application 11         10              V: 2.0 10/07