{"id":130370,"date":"2025-03-25T02:37:31","date_gmt":"2025-03-25T02:37:31","guid":{"rendered":"https:\/\/staging.occominternet.com\/?page_id=130370"},"modified":"2026-05-20T18:05:50","modified_gmt":"2026-05-20T08:05:50","slug":"occom-financial-hardship-application","status":"publish","type":"page","link":"https:\/\/staging.occominternet.com\/?page_id=130370","title":{"rendered":"OCCOM Financial Hardship Application"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"130370\" class=\"elementor elementor-130370\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-6bf7352 e-flex e-con-boxed e-con e-parent\" data-id=\"6bf7352\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-c962f28 elementor-widget elementor-widget-spacer\" data-id=\"c962f28\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-cccb803 elementor-widget elementor-widget-heading\" data-id=\"cccb803\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">OCCOM Financial Hardship Application<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-74e7352 elementor-widget elementor-widget-shortcode\" data-id=\"74e7352\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><script>\nvar 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#112337;--gf-ctrl-choice-size: var(--gf-ctrl-choice-size-md);--gf-ctrl-checkbox-check-size: var(--gf-ctrl-checkbox-check-size-md);--gf-ctrl-radio-check-size: var(--gf-ctrl-radio-check-size-md);--gf-ctrl-btn-font-size: var(--gf-ctrl-btn-font-size-md);--gf-ctrl-btn-padding-x: var(--gf-ctrl-btn-padding-x-md);--gf-ctrl-btn-size: var(--gf-ctrl-btn-size-md);--gf-ctrl-btn-border-color-secondary: #686e77;--gf-ctrl-file-btn-bg-color-hover: #EBEBEB;--gf-field-img-choice-size: var(--gf-field-img-choice-size-md);--gf-field-img-choice-card-space: var(--gf-field-img-choice-card-space-md);--gf-field-img-choice-check-ind-size: var(--gf-field-img-choice-check-ind-size-md);--gf-field-img-choice-check-ind-icon-size: var(--gf-field-img-choice-check-ind-icon-size-md);--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style><form method='post' enctype='multipart\/form-data'  id='gform_69'  action='\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F130370' data-formid='69' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_69' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_69_1\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>We understand Financial Hardship is different for everyone and we will work with you to identify the best solution for your individual circumstances.\n Applying for financial hardship assistance or entering into an arrangement is free of charge.\n You have the right to apply whenever you need it. We will prioritise keeping you connected.\nIf you are seeking short term assistance or been impacted by domestic or family violence, you are not required to provide supporting documentation.\n\nPlease complete this form and we will contact you within 5 business days with assistance options.<\/p><\/li><li id=\"field_69_15\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Personal Details<\/h2><div class='gsection_description' id='gfield_description_69_15'>We need your details to verify that you are the account holder.<\/div><\/li><li id=\"field_69_16\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_16'>Customer Account Number \/ Registered Contact Details<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_69_16' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_69_2\" class=\"gfield gfield--type-radio gfield--type-choice hide-input-box gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Have you ever applied for the Financial Hardship previously?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_69_2'>\n\t\t\t<li class='gchoice gchoice_69_2_0'>\n\t\t\t\t<input name='input_2' type='radio' value='Yes'  id='choice_69_2_0'    \/>\n\t\t\t\t<label for='choice_69_2_0' id='label_69_2_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_69_2_1'>\n\t\t\t\t<input name='input_2' type='radio' value='No, this is my first time for this account.'  id='choice_69_2_1'    \/>\n\t\t\t\t<label for='choice_69_2_1' id='label_69_2_1' class='gform-field-label gform-field-label--type-inline'>No, this is my first time for this account.<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_69_17\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span> <span class=\"required\">*<\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_69_17'>\n                            \n                            <span id='input_69_17_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_17.3' id='input_69_17_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_69_17_3' class='gform-field-label gform-field-label--type-sub '>First <span class=\"required\">*<\/span><\/label>\n                                                <\/span>\n                            \n                            <span id='input_69_17_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_17.6' id='input_69_17_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_69_17_6' class='gform-field-label gform-field-label--type-sub '>Last <span class=\"required\">*<\/span><\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_69_19\" class=\"gfield gfield--type-radio gfield--type-choice hide-input-box gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Preferred contact method<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_69_19'>\n\t\t\t<li class='gchoice gchoice_69_19_0'>\n\t\t\t\t<input name='input_19' type='radio' value='Home Phone'  id='choice_69_19_0'    \/>\n\t\t\t\t<label for='choice_69_19_0' id='label_69_19_0' class='gform-field-label gform-field-label--type-inline'>Home Phone<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_69_19_1'>\n\t\t\t\t<input name='input_19' type='radio' value='Email'  id='choice_69_19_1'    \/>\n\t\t\t\t<label for='choice_69_19_1' id='label_69_19_1' class='gform-field-label gform-field-label--type-inline'>Email<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_69_19_2'>\n\t\t\t\t<input name='input_19' type='radio' value='Mobile'  id='choice_69_19_2'    \/>\n\t\t\t\t<label for='choice_69_19_2' id='label_69_19_2' class='gform-field-label gform-field-label--type-inline'>Mobile<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_69_20\" class=\"gfield gfield--type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_20'>Home Phone Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_20' id='input_69_20' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_69_22\" class=\"gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_22'>Email Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_22' id='input_69_22' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_69_23\" class=\"gfield gfield--type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_23'>Mobile Phone Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_23' id='input_69_23' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_69_28\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_28'>Language<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_28' id='input_69_28' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='ToBeConfirmed' >To Be Confirmed<\/option><option value='English' >English<\/option><option value='Chinese' >Mandarin<\/option><option value='Cantonese' >Cantonese<\/option><option value='Hindu' >Hindu<\/option><option value='Korean' >Korean<\/option><option value='Malay' >Malay<\/option><option value='Vietnamese' >Vietnamese<\/option><option value='Others' >Others<\/option><\/select><\/div><\/li><li id=\"field_69_30\" class=\"gfield gfield--type-time gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Best time to reach from<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class=\"ginput_container ginput_complex gform-grid-row\"><div class=\"clear-multi\">\n                        <div class='gfield_time_hour ginput_container ginput_container_time gform-grid-col' id='input_69_30'>\n                            <input type='number' name='input_30[]' id='input_69_30_1' value=''  min='0' max='12' step='1'  placeholder='HH' aria-required='true'   \/> <i>:<\/i>\n                            <label class='gform-field-label gform-field-label--type-sub hour_label screen-reader-text' for='input_69_30_1'>Hours<\/label>\n                        <\/div>\n                        \n                        <div class='gfield_time_minute ginput_container ginput_container_time gform-grid-col'>\n                            <input type='number' name='input_30[]' id='input_69_30_2' value=''  min='0' max='59' step='1'  placeholder='MM' aria-required='true'  \/>\n                            <label class='gform-field-label gform-field-label--type-sub minute_label screen-reader-text' for='input_69_30_2'>Minutes<\/label>\n                        <\/div>\n                        <div class='gfield_time_ampm ginput_container ginput_container_time below gform-grid-col' >\n                                \n                                <select name='input_30[]' id='input_69_30_3'  >\n                                    <option value='am' >AM<\/option>\n                                    <option value='pm' >PM<\/option>\n                                <\/select> \n                                <label class='gform-field-label gform-field-label--type-sub am_pm_label screen-reader-text' for='input_69_30_3'>AM\/PM<\/label>                                \n                           <\/div>\n                    <\/div><\/div><\/li><li id=\"field_69_31\" class=\"gfield gfield--type-time gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Best time to reach to<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class=\"ginput_container ginput_complex gform-grid-row\"><div class=\"clear-multi\">\n                        <div class='gfield_time_hour ginput_container ginput_container_time gform-grid-col' id='input_69_31'>\n                            <input type='number' name='input_31[]' id='input_69_31_1' value=''  min='0' max='12' step='1'  placeholder='HH' aria-required='true'   \/> <i>:<\/i>\n                            <label class='gform-field-label gform-field-label--type-sub hour_label screen-reader-text' for='input_69_31_1'>Hours<\/label>\n                        <\/div>\n                        \n                        <div class='gfield_time_minute ginput_container ginput_container_time gform-grid-col'>\n                            <input type='number' name='input_31[]' id='input_69_31_2' value=''  min='0' max='59' step='1'  placeholder='MM' aria-required='true'  \/>\n                            <label class='gform-field-label gform-field-label--type-sub minute_label screen-reader-text' for='input_69_31_2'>Minutes<\/label>\n                        <\/div>\n                        <div class='gfield_time_ampm ginput_container ginput_container_time below gform-grid-col' >\n                                \n                                <select name='input_31[]' id='input_69_31_3'  >\n                                    <option value='am' >AM<\/option>\n                                    <option value='pm' >PM<\/option>\n                                <\/select> \n                                <label class='gform-field-label gform-field-label--type-sub am_pm_label screen-reader-text' for='input_69_31_3'>AM\/PM<\/label>                                \n                           <\/div>\n                    <\/div><\/div><\/li><li id=\"field_69_29\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_29'>Occupation<\/label><div class='ginput_container ginput_container_text'><input name='input_29' id='input_69_29' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_69_18\" class=\"gfield gfield--type-radio gfield--type-choice hide-input-box gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >What&#039;s your main reason for requesting payment assistance?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_69_18'>\n\t\t\t<li class='gchoice gchoice_69_18_0'>\n\t\t\t\t<input name='input_18' type='radio' value='Change of employment'  id='choice_69_18_0'    \/>\n\t\t\t\t<label for='choice_69_18_0' id='label_69_18_0' class='gform-field-label gform-field-label--type-inline'>Change of employment<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_69_18_1'>\n\t\t\t\t<input name='input_18' type='radio' value='Loss of employment'  id='choice_69_18_1'    \/>\n\t\t\t\t<label for='choice_69_18_1' id='label_69_18_1' class='gform-field-label gform-field-label--type-inline'>Loss of employment<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_69_18_2'>\n\t\t\t\t<input name='input_18' type='radio' value='Medical issues'  id='choice_69_18_2'    \/>\n\t\t\t\t<label for='choice_69_18_2' id='label_69_18_2' class='gform-field-label gform-field-label--type-inline'>Medical issues<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_69_18_3'>\n\t\t\t\t<input name='input_18' type='radio' value='Reduction of Income'  id='choice_69_18_3'    \/>\n\t\t\t\t<label for='choice_69_18_3' id='label_69_18_3' class='gform-field-label gform-field-label--type-inline'>Reduction of Income<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_69_18_4'>\n\t\t\t\t<input name='input_18' type='radio' value='Impacted by disaster'  id='choice_69_18_4'    \/>\n\t\t\t\t<label for='choice_69_18_4' id='label_69_18_4' class='gform-field-label gform-field-label--type-inline'>Impacted by disaster<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_69_18_5'>\n\t\t\t\t<input name='input_18' type='radio' value='Domestic and family violence'  id='choice_69_18_5'    \/>\n\t\t\t\t<label for='choice_69_18_5' id='label_69_18_5' class='gform-field-label gform-field-label--type-inline'>Domestic and family violence<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_69_18_6'>\n\t\t\t\t<input name='input_18' type='radio' value='Bankrupt'  id='choice_69_18_6'    \/>\n\t\t\t\t<label for='choice_69_18_6' id='label_69_18_6' class='gform-field-label gform-field-label--type-inline'>Bankrupt<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_69_18_7'>\n\t\t\t\t<input name='input_18' type='radio' value='Family death'  id='choice_69_18_7'    \/>\n\t\t\t\t<label for='choice_69_18_7' id='label_69_18_7' class='gform-field-label gform-field-label--type-inline'>Family death<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_69_18_8'>\n\t\t\t\t<input name='input_18' type='radio' value='gf_other_choice'  id='choice_69_18_8'   onfocus=\"jQuery(this).next('input').focus();\" \/>\n\t\t\t\t<input class='small' id='input_69_18_other' name='input_18_other' type='text' value='Other' aria-label='Other' onfocus='jQuery(this).prev(\"input\")[0].click(); if(jQuery(this).val() == \"Other\") { jQuery(this).val(\"\"); }' onblur='if(jQuery(this).val().replace(\" \", \"\") == \"\") { jQuery(this).val(\"Other\"); }'   \/>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_69_8\" class=\"gfield gfield--type-radio gfield--type-choice hide-input-box gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >What type of relief are you seeking?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_69_8'>\n\t\t\t<li class='gchoice gchoice_69_8_0'>\n\t\t\t\t<input name='input_8' type='radio' value='Payment arrangement'  id='choice_69_8_0'    \/>\n\t\t\t\t<label for='choice_69_8_0' id='label_69_8_0' class='gform-field-label gform-field-label--type-inline'>Payment arrangement<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_69_8_1'>\n\t\t\t\t<input name='input_8' type='radio' value='Payment Deferral'  id='choice_69_8_1'    \/>\n\t\t\t\t<label for='choice_69_8_1' id='label_69_8_1' class='gform-field-label gform-field-label--type-inline'>Payment Deferral<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_69_8_2'>\n\t\t\t\t<input name='input_8' type='radio' value='Restriction of service'  id='choice_69_8_2'    \/>\n\t\t\t\t<label for='choice_69_8_2' id='label_69_8_2' class='gform-field-label gform-field-label--type-inline'>Restriction of service<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_69_8_3'>\n\t\t\t\t<input name='input_8' type='radio' value='Downgrading of plan'  id='choice_69_8_3'    \/>\n\t\t\t\t<label for='choice_69_8_3' id='label_69_8_3' class='gform-field-label gform-field-label--type-inline'>Downgrading of plan<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_69_8_4'>\n\t\t\t\t<input name='input_8' type='radio' value='Waiving of fee'  id='choice_69_8_4'    \/>\n\t\t\t\t<label for='choice_69_8_4' id='label_69_8_4' class='gform-field-label gform-field-label--type-inline'>Waiving of fee<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_69_8_5'>\n\t\t\t\t<input name='input_8' type='radio' value='gf_other_choice'  id='choice_69_8_5'   onfocus=\"jQuery(this).next('input').focus();\" \/>\n\t\t\t\t<input class='small' id='input_69_8_other' name='input_8_other' type='text' value='Other' aria-label='Other' onfocus='jQuery(this).prev(\"input\")[0].click(); if(jQuery(this).val() == \"Other\") { jQuery(this).val(\"\"); }' onblur='if(jQuery(this).val().replace(\" \", \"\") == \"\") { jQuery(this).val(\"Other\"); }'   \/>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_69_9\" class=\"gfield gfield--type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_9'>Please tell us the amount involved, if known.<\/label><div class='ginput_container ginput_container_number'><input name='input_9' id='input_69_9' type='text' step='any'   value='' class='medium'    placeholder='$'  aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_69_5\" class=\"gfield gfield--type-radio gfield--type-choice hide-input-box gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Please specify the duration of payment installments?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_69_5'>\n\t\t\t<li class='gchoice gchoice_69_5_0'>\n\t\t\t\t<input name='input_5' type='radio' value='Monthly'  id='choice_69_5_0'    \/>\n\t\t\t\t<label for='choice_69_5_0' id='label_69_5_0' class='gform-field-label gform-field-label--type-inline'>Monthly<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_69_5_1'>\n\t\t\t\t<input name='input_5' type='radio' value='Bi-Weekly'  id='choice_69_5_1'    \/>\n\t\t\t\t<label for='choice_69_5_1' id='label_69_5_1' class='gform-field-label gform-field-label--type-inline'>Bi-Weekly<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_69_5_2'>\n\t\t\t\t<input name='input_5' type='radio' value='Weekly'  id='choice_69_5_2'    \/>\n\t\t\t\t<label for='choice_69_5_2' id='label_69_5_2' class='gform-field-label gform-field-label--type-inline'>Weekly<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_69_10\" class=\"gfield gfield--type-number field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_10'>Could you kindly provide the amount payable by you?<\/label><div class='ginput_container ginput_container_number'><input name='input_10' id='input_69_10' type='text' step='any'   value='' class='medium'    placeholder='$'  aria-invalid=\"false\" aria-describedby=\"gfield_description_69_10\" \/><\/div><div class='gfield_description' id='gfield_description_69_10'>(Note - Minimum amount should be $50 for weekly, $100  for Bi- weekly, $150 for monthly)<\/div><\/li><li id=\"field_69_11\" class=\"gfield gfield--type-fileupload field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='gform_browse_button_69_11'>Please attach a document to support your Financial Hardship application. This may be:<\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_69_11' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_69_11&quot;,&quot;container&quot;:&quot;gform_multifile_upload_69_11&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_69_11&quot;,&quot;filelist&quot;:&quot;gform_preview_69_11&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/staging.occominternet.com\\\/?gf_page=405ff9ff4008a6f&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/staging.occominternet.com\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/staging.occominternet.com\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;*&quot;}],&quot;max_file_size&quot;:&quot;33554432b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:69,&quot;field_id&quot;:11,&quot;_gform_file_upload_nonce_69_11&quot;:&quot;e52fcab589&quot;},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_69_11&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phar&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_69_11' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_69_11' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_69_11 gfield_description_69_11\"  >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_69_11'>Max. file size: 32 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_69_11'><\/ul> <div id='gform_preview_69_11' class='ginput_preview_list'><\/div><\/div><div class='gfield_description' id='gfield_description_69_11'>- Centrelink documentation (e.g. JobSeeker payment)<br>\n- Redundancy paperwork<br>\n- Medical record<br>\n- Bankruptcy notice\/insolvency<br>\n- Reduced working hours payslip or employer's letter<br>\n- Business financial or sales records showing reduced turnover<\/div><\/li><li id=\"field_69_12\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_69_12'>Please add any comment you may wish to make regarding your situation.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_12' id='input_69_12' class='textarea medium'   maxlength='500'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_69_27\" class=\"gfield gfield--type-radio gfield--type-choice hide-input-box gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text' ><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_69_27'>\n\t\t\t<li class='gchoice gchoice_69_27_0'>\n\t\t\t\t<input name='input_27' type='radio' value='I acknowledge that I am providing personal information to OCCOM Internet Pty Ltd and that I have read the Collection Notice.'  id='choice_69_27_0'    \/>\n\t\t\t\t<label for='choice_69_27_0' id='label_69_27_0' class='gform-field-label gform-field-label--type-inline'>I acknowledge that I am providing personal information to OCCOM Internet Pty Ltd and that I have read the Collection Notice.<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><\/ul><\/div>\n        <div class='gform-footer gform_footer top_label'> <button id=\"gform_submit_button_69\" type=\"submit\" class=\"gform_button button\" onclick=\"gform.submission.handleButtonClick(this);\">Submit<\/button> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_69' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_69' id='gform_theme_69' value='legacy' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_69' id='gform_style_settings_69' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_69' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='69' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='AUD' value='vfW9AUPJES5661+p6OP8lTSIeBNmPuS2J0ufX48\/jd6gKfnxr6AY3iLGFzTMo0kk3CFYtQqLTXEh1mWH2cVRha4iz65AQJWObaYKFJXrbz56P+Y=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_69' value='WyJbXSIsIjYxZTFiYjAyNWE4Mzg1MTJjZmYwMjg0ZTNjY2Y0ZjIxIl0=' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_target_page_number_69' id='gform_target_page_number_69' value='0' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_source_page_number_69' id='gform_source_page_number_69' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            <input type='hidden' name='gform_uploaded_files' id='gform_uploaded_files_69' value='' \/>\n        <\/div>\n                        <\/form>\n                        <\/div><script>\ngform.initializeOnLoaded( function() {gformInitSpinner( 69, 'https:\/\/staging.occominternet.com\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery('#gform_ajax_frame_69').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_69');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_69').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){form_content.find('form').css('opacity', 0);jQuery('#gform_wrapper_69').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_69').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_69').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/  }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_69').val();gformInitSpinner( 69, 'https:\/\/staging.occominternet.com\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery(document).trigger('gform_page_loaded', [69, current_page]);window['gf_submitting_69'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = contents;}jQuery('#gform_wrapper_69').replaceWith(confirmation_content);jQuery(document).trigger('gform_confirmation_loaded', [69]);window['gf_submitting_69'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_69').text());}else{jQuery('#gform_69').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger(\"gform_pre_post_render\", [{ formId: \"69\", currentPage: \"current_page\", abort: function() { this.preventDefault(); } }]);        if (event && event.defaultPrevented) {                return;        }        const gformWrapperDiv = document.getElementById( \"gform_wrapper_69\" );        if ( 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