Claim for Parenting Payment - Department of Human Services

Transcription

Claim for
Parenting Payment
When to use this form
Use this form to claim Parenting Payment:
• if you are single and have a dependent child under the age of 8 years in your care, OR
• if you are partnered and have a dependent child under the age of 6 years in your care.
What else you will
need to provide
You will need to provide proof of identity. There is a complete list of acceptable documents
in the Information Booklet.
Online Services
Claiming Parenting Payment online is faster. To claim online go to
humanservices.gov.au/centrelinkonline
Processing this form will take longer. You should receive advice about your claim for Parenting
Payment within 28 days of lodging this form and any requested documents.
www.
Express Plus Apps – download Express Plus Apps from the App Store or Google Play™
(App Store is a service mark of Apple Inc., registered in the U.S. and other countries. Google
Play is a trademark of Google Inc.). You can do some of your Centrelink business and read
important updates about payments and services we provide on-the-go. For more information
about Express Plus Apps, visit humanservices.gov.au/expressplus
www.
You can access your Centrelink, Medicare and Child Support Online Services through myGov.
myGov is a fast, simple way to access a range of government services online with one
username, one password, all from one secure location. To create a myGov account, go to
my.gov.au
www.
Filling in this form
• Please use black or blue pen.
• Print in BLOCK LETTERS
• Mark boxes like this with a or .
Go to 5 skip to the question number shown. You do not
• Where you see a box like this
need to answer the questions in between.
Returning your form
Check that all required questions are answered and that the form is signed and dated.
Return this form and any supporting documents to us within 14 days so we can process
your application or claim. If you cannot do this within 14 days, contact us for extra time.
If extra time is required, you must contact us at the earliest possible date to make an
arrangement.
You can return this form and any supporting documents:
• online – submit your documents online. For more information about how to access an
Online Account or how to lodge documents online, go to
humanservices.gov.au/submitdocumentsonline
• by post – return your documents by sending them to:
www.
Department of Human Services
Reply Paid 7802
CANBERRA BC ACT 2610
• in person – if you are unable to submit this form and any supporting documents online
or by post, you can provide them in person to one of our Service Centres.
To establish your identity, you will be required to attend one of our Service Centres to provide
original documents.
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For more information
Refer to Information you need to know about your claim for Parenting Payment (Ci008)
(Information Booklet) on our website humanservices.gov.au/parentingpayment or call
us on 136 150 or visit one of our Service Centres.
www.
If you need a translation of any documents for our business, we can arrange this for you
free of charge.
To speak to us in languages other than English, call 131 202.
Note: Call charges apply – calls from mobile phones may be charged at a higher rate.
If you have a hearing or speech impairment, you can contact the TTY service on
Freecall™ 1800 810 586. A TTY phone is required to use this service.
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1
6
Do you need an interpreter when dealing with us?
This includes an interpreter for people who have a hearing or
speech impairment.
No
Yes
Have you ever used or been known by any other name
(e.g. name at birth, maiden name, previous married name,
Aboriginal or tribal name, alias, adoptive name, foster name)?
Go to 3
No
Go to next question
Go to next question
Yes
Give details below
1 Other name
2
What is your preferred spoken language?
3
What is your preferred written language?
Type of name (e.g. name at birth)
2 Other name
4
Are you the principal carer of a dependent child under 6 years
(for partnered claimants) or under 8 years (for single claimants)?
Note: If you are claiming Parenting Payment as a single
claimant and your youngest child is aged 6 or 7 years, you will
have participation requirements. For information about
participation requirements, go to our website
humanservices.gov.au/parentingpayment
Type of name (e.g. maiden name)
www.
No
Yes
If you have more than 2 other names, attach a separate sheet
with details.
You will not be entitled to Parenting Payment.
Please call us on 136 150.
Go to next question
7
Your sex
Male
Personal details
5
Female
Your name
Mr
Mrs
Miss
Ms
Other
8
Your date of birth
/
Family name
9
/
Your permanent address
First given name
Second given name
Postcode
10 Your postal address (if different to above)
Postcode
CLK0SC277 1501
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11 Please read this before answering the following question.
14 Are you of Australian South Sea Islander origin?
No
If you provide an email address or mobile phone number, you
may receive electronic messages (SMS or email) from us. To
read the Terms and Conditions, go to our website
humanservices.gov.au/em or visit one of our Service Centres.
Yes
www.
15 Do you want another person or organisation to enquire or act on
your behalf when dealing with us?
Your contact details
Home phone number (
Go to next question
No
)
Is this a silent number? No
Whose name is the phone account in?
Yes
Yes
You will need to complete and attach an
Authorising a person or organisation to
enquire or act on your behalf form (SS313).
If you do not have this form or want more
information about nominee arrangements,
go to our website
humanservices.gov.au/nominees or call us
on 136 150.
My name
My partner’s name
Another name
www.
Mobile phone number
Is this a silent number? No
Whose name is the mobile phone account in?
Fax number (
)
Work phone number (
)
Alternative phone number (
)
Yes
Residence details
My name
My partner’s name
Another name
'Permanently' means you normally live in Australia on a
long-term basis. Holidays or short trips outside Australia would
not affect this.
Are you living in Australia permanently?
No
Yes
Email
17 Have you lived or travelled outside Australia since
1 September 1994, including short trips and holidays?
@
The answer to this question may enable Human Services to
access electronic records held by Australia’s immigration
department and help verify your Australian residence.
12 Do you currently get another type of Social Security payment or
Family Tax Benefit?
Go to next question
No
Yes
Your Centrelink Reference Number (if known)
No
Go to next question
Yes
Give details below
Passport number
Country of issue
13 Please read this before answering the following questions.
Questions 13 and 14 are optional and will not affect your
payment. If you do answer, the information will help us to
continue to improve services to Aboriginal and Torres Strait
Islander Australians and Australian South Sea Islanders.
Australian South Sea Islanders are the descendants of Pacific
Islander labourers brought from the Western Pacific in the
19th Century.
18 Are you an Australian citizen who was born in Australia?
No
Go to next question
Are you of Aboriginal or Torres Strait Islander Australian origin?
If you are of both Aboriginal and Torres Strait Islander Australian
origin, please tick both ‘Yes’ boxes.
No
Yes – Aboriginal Australian
You will need to provide proof of your Australian
residence status (e.g. citizenship papers,
passport or other documentation).
Go to 29
Yes
19 What is your country of birth?
Yes – Torres Strait Islander Australian
20 When did you start living in Australia?
/
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/
21 Did you start living in Australia before 1965?
No
Go to next question
Yes
Give details below
29 Except for short trips or holidays, have you EVER lived outside
Australia?
No
Go to next question
Yes
Name of the ship or airline on which you arrived
Name of the place where you first arrived/disembarked
What was your name when you first arrived in Australia?
1 Country of residence
From
22 What is your country of citizenship?
Date granted
Australia
/
/
/
To
/
/
To
/
/
To
/
/
To
/
/
To
/
/
To
/
/
Go to next
question
/
List ALL countries, INCLUDING AUSTRALIA, you have
lived in SINCE BIRTH.
If you were born outside Australia, include the country
where you were born.
Include the period(s) you have lived in each country.
Do NOT include short trips or holidays.
Country of citizenship
Other
From
Permanent
Temporary
Unknown (e.g. arrived
on parent’s passport)
/
23 What type of visa did you arrive on?
New Zealand passport
(special category visa)
/
Go to 25
From
/
/
Go to next question
Go to next question
Go to 25
From
/
/
24 Your visa details on arrival
Visa sub class
Date visa granted
/
/
From
25 Has your visa changed since you arrived in Australia?
/
No
Go to next question
Yes
Most recent visa details
Visa sub class
/
Date visa granted
/
From
/
/
/
If you require more space, attach a separate sheet with details.
26 Are you a refugee or former refugee?
No
Yes
27 Did your partner or either of your parents arrive on a refugee or
humanitarian visa?
No
Yes
28 Did someone provide you with an Assurance of Support for your
migration to Australia?
No
Not sure
Yes
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32 What is your date of marriage or relationship registration?
Payment details
/
30 Where do you want your payment made?
The bank, building society or credit union account must be in
your name. A joint account is acceptable.
Do NOT include an account used exclusively for funding from
the National Disability Insurance Scheme.
/
Go to 34
33 When did you and your partner start living together as a member
of a couple?
/
Name of bank, building
society or credit union
/
34 Do you currently live in the same home as your partner?
Branch where the
account is held
Branch number (BSB)
Account number
(this may not be your
card number)
No
Go to next question
Yes
Go to 44
35 Why are you not living with your partner?
Partner’s illness
Balance of account $
Your illness
Partner in prison
Account held in the name(s) of
Partner’s employment
Other
Give details below
Attach proof of account balances (e.g. ATM slips,
statements, passbooks).
36 Period not living with your partner
Relationship status
We recognise both opposite-sex and same-sex relationships.
This includes de facto relationships and relationships
registered under state or territory law.
Select ONE option below that best describes your current
relationship status.
From
/
/
To
/
/
OR indefinite
Go to 44
37 Did your deceased partner ever live outside Australia?
No
What is your CURRENT relationship status?
Yes
int
Married
Go to 32
Registered relationship
(opposite-sex or same-sex relationship
registered under state or territory law)
Go to 32
Partnered
(living together in an opposite-sex or
same-sex relationship, including de facto)
Go to 32
Separated
(previously lived with an opposite-sex or
same-sex partner, including in a marriage,
registered or de facto relationship)
Go to 39
Divorced
Go to 40
Widowed
(previously partnered with an opposite-sex or
same-sex partner, including in a marriage,
registered or de facto relationship)
Go to 37
Never married or lived with a partner
Go to 62
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38 Please give the following details about your deceased partner
Full name
Date of birth
/
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Go to 62
Date of death
/
/
/
42 Is there any chance of a reconciliation?
39 Give the names and contact details of 2 people we can contact
who can confirm your separation (who are not closely related or
members of your immediate family).
No
1 Full name
Not sure
int
Yes
int
43 Are there any reasons for your separation that you would like to
Address
discuss with a social worker?
No
Go to 62
Yes
Postcode
44 Your partner’s name
Phone number
(
Mr
)
Mrs
Miss
Relationship to you
Family name
How long have you known this person?
First given name
2 Full name
Second given name
Address
Ms
Other
45 Has your partner ever used or been known by any other name
(e.g. name at birth, maiden name, previous married name,
Aboriginal or tribal name, alias, adoptive name, foster name)?
Postcode
Phone number
(
No
Go to next question
Yes
Give details below
1 Other name
)
Relationship to you
Type of name (e.g. name at birth)
How long have you known this person?
2 Other name
40 Do you live in the same home as your former partner?
No
Go to next question
Yes
Go to 42
Type of name (e.g. maiden name)
SS293
41 Please give the following details about your former partner
If your partner has more than 2 other names, attach a separate
sheet with details.
Full name
Date of birth
/
Date relationship ended
/
/
46 Your partner’s sex
/
Male
Female
Current address (if known)
47 Your partner’s date of birth
/
Postcode
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/
48 Does your partner currently get another type of Social Security
55 Did your partner start living in Australia before 1965?
payment or Family Tax Benefit?
No
Go to next question
Give details below
No
Go to next question
Yes
Yes
Your partner’s Centrelink Reference Number (if known)
Name of the ship or airline on which your partner arrived
Name of the place where your partner first arrived/disembarked
49 Your partner’s permanent address
What was your partner’s name when they first arrived in Australia?
Postcode
56 What is your partner’s country of citizenship?
Australia
Date granted
/
‘Permanently’ means you normally live in Australia on a
long-term basis. Holidays or short trips outside Australia would
not affect this.
Other
Go to next
question
/
Country of citizenship
Is your partner living in Australia permanently?
No
57 What is your partner’s current type of visa?
Yes
New Zealand passport
(special category visa)
51 Has your partner lived or travelled outside Australia since
Permanent
1 September 1994, including short trips and holidays?
Temporary
access electronic records held by Australia’s immigration
department and help verify your partner’s Australian residence.
No
Go to next question
Yes
Give details below
Unknown (e.g. arrived
on parent’s passport)
Visa sub class
52 Is your partner an Australian citizen who was born in Australia?
You will need to provide proof of your partner’s
Australian residence status (e.g. citizenship
papers, passport or other documentation).
Go to next question
Go to 59
53 What is your partner’s country of birth?
54 When did your partner start living in Australia?
/
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Go to next question
Go to 59
Date visa granted
/
Country of issue
Yes
Go to next question
58 Your partner’s current visa details
Passport number
No
Go to 59
/
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/
59 Except for short trips or holidays, has your partner EVER lived
outside Australia?
No
Go to next question
Yes
List ALL countries, INCLUDING AUSTRALIA, your
partner has lived in SINCE BIRTH.
Include the period(s) your partner has lived in Australia.
If your partner was born outside Australia, include the
country where your partner was born.
Do NOT include short trips or holidays.
From
/
/
To
/
Give details of each person who shares your accommodation.
Do not include immediate family members.
/
Person 1 Name
From
/
/
To
/
Male
/
/
Age
When did you start
sharing with this person?
Sex
/
From
The following questions are to be completed if you share your
accommodation with anyone other than an immediate family
member.
This includes anyone who:
• regularly stays any number of nights per week
• uses your home as a base (e.g. truck drivers, miners, flight
attendants, fishermen, members of the armed forces).
We need some details about your living arrangements to work
out your correct payment.
The questions on this form will assist us to decide whether we
need additional information.
Female
/
/
What is your relationship to this person?
To
/
/
Have you shared accommodation, at another address,
with this person?
No
Yes
From
/
/
To
/
/
Have you and this person previously lived together as a couple
(e.g. married, partnered, de facto or in a registered relationship)?
No
Yes
SS293
From
/
/
To
/
/
Do you and this person share the parent/guardianship of any
children?
If you require more space, attach a separate sheet with details.
No
Yes
60 Do you give permission for your partner to discuss your payments
SS284
with us?
You can change this authority at any time.
Have you and this person ever had any joint financial
commitments (e.g. joint bank account, mortgage or other loans)?
No
No
Yes
Yes
Give details below
SS284
Living arrangements
61 Are you married, in a registered relationship or partnered
If you participate in activities jointly with this person, are you
considered to be a couple?
(including de facto)?
No
Go to next question
Yes
Go to 64
No
Yes
SS284
62 Do you share your accommodation with anyone other than an
immediate family member?
No
Go to 64
Yes
Go to next question
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Give details below
Continued
Continued
Person 2 Name
When did you start
Sex
Male
Person 3 Name
Age
Female
/
When did you start
Sex
/
Male
Age
Female
/
/
with this person?
with this person?
No
No
Yes
Yes
No
No
Yes
Yes
SS293
SS293
children?
children?
No
No
Yes
Yes
SS284
SS284
No
No
Yes
Give details below
Yes
SS284
Give details below
SS284
No
No
Yes
Give details below
Yes
SS284
Give details below
SS284
If you share with more than 3 people, attach a separate sheet
with details.
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About your dependent children or students
64 Provide details of child(ren) in your (and/or your partner's) care under 18 years of age or full-time students under 22 years of age?
If you have more than 2 dependent children, copy and attach pages (11 and 12) for each additional child before completing the details
for child 1.
Child 1
65 Family name
The term ‘parent’ refers to a natural parent, adoptive parent
or a person who is legally responsible for a child born
through an artificial conception procedure or where a
surrogacy court order is in place.
First given name
Which of the following best describes your relationship to
this child?
Second given name
Parent
Grandparent
66 Has this child ever been known by any other names?
No
Go to next question
Yes
List the other names
Step-parent
Foster carer
Other
Give details below
72 Does this child currently live with you?
No
67 Sex
Yes
Male
73 Do you (and/or your partner) share the care of this child with
Female
another person? Do not include school/day care arrangements.
68 Date of birth
/
/
No
Go to next question
Yes
What is the percentage of your (or your partner’s)
care of this child?
%
69 What is this child’s country of birth?
74 Does this child receive a payment from any Commonwealth,
70 Has this child EVER lived or travelled outside Australia, including
short trips and holidays?
State or Territory Government?
Go to next question
No
Yes
Give details below
access electronic records held by Australia's immigration
department and verify your child's Australian residence.
No
Go to next question
Yes
Give details below
75 Is this child 5 years or older?
Passport number
No
Go to 78
Yes
Go to next question
76 Is this child in full-time education?
Country of issue
No
Yes
77 Does this child have any income?
No
Go to next question
Yes
Amount
$
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per week
Child 1
78 Do you receive Family Tax Benefit for this child?
No
Attach proof of birth (e.g. birth certificate)
for this child if you have not previously
provided it to us.
Yes
79 Do you have another dependent child?
No
Yes
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Go to 80 on page 15
If you (and/or your partner) have more than
2 dependent children in your care (if you have not
already copied pages 11 and 12) copy and attach
pages 13 and 14 for each additional child before
completing the details for child 2.
Go to next question in the next column
12 of 35
Child 2
65 Family name
The term ‘parent’ refers to a natural parent, adoptive parent
or a person who is legally responsible for a child born
through an artificial conception procedure or where a
surrogacy court order is in place.
First given name
Which of the following best describes your relationship to
this child?
Second given name
Parent
Grandparent
66 Has this child ever been known by any other names?
No
Go to next question
Yes
List the other names
Step-parent
Foster carer
Other
Give details below
72 Does this child currently live with you?
No
67 Sex
Yes
Male
73 Do you (and/or your partner) share the care of this child with
Female
another person? Do not include school/day care arrangements.
68 Date of birth
/
/
No
Go to next question
Yes
What is the percentage of your (or your partner’s)
care of this child?
%
69 What is this child’s country of birth?
74 Does this child receive a payment from any Commonwealth,
70 Has this child EVER lived or travelled outside Australia, including
short trips and holidays?
State or Territory Government?
Go to next question
No
Yes
Give details below
access electronic records held by Australia's immigration
department and verify your child's Australian residence.
No
Go to next question
Yes
Give details below
75 Is this child 5 years or older?
Passport number
No
Go to 78
Yes
Go to next question
76 Is this child in full-time education?
Country of issue
No
Yes
77 Does this child have any income?
No
Go to next question
Yes
Amount
$
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per week
Child 2
78 Do you receive Family Tax Benefit for this child?
No
Attach proof of birth (e.g. birth certificate)
for this child if you have not previously
provided it to us.
Yes
79 Do you have another dependent child?
No
Yes
Go to next question
Attach details of each additional child.
Go to next question
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Accommodation
Tax details
83 In the last 14 days:
• have you (and/or your partner) claimed or been paid a Social
Security payment, and
• did you (and/or your partner) provide us with your
accommodation details and those details have not changed?
You are not breaking the law if you do not give us your (and
your partner’s) tax file number(s), but if you (and your partner)
do not provide them to us, or authorise us to get them from
the Australian Taxation Office, you may not be paid.
In giving us your (and your partner’s) tax file number in relation
to this claim you authorise us to use your (and your partner’s)
tax file number for other social security payments and services
in future where necessary.
Go to next question
Not sure
Go to next question
Not sure
Go to next question
Do not answer questions 84 to 107.
Go to 108
84 Do you (and/or your partner) own a home but live elsewhere?
Go to 82
Yes
Go to next question
Yes
Have you (and your partner) given us your tax file number before?
No
No
No
Go to next question
Yes
What is the reason you live away from
the home you own?
Travelling away from your home
81 Do you (and your partner) have a tax file number?
Being cared for away from your home
You
No
Yes
Caring for someone away from your home
Living away from home to study
Other
Your tax file number
Give details
below
Your partner
No
Yes
Your partner’s tax file number
85 Which of the following best describes where you live?
If your only income for this financial year is the payment you
are now claiming, you may not have to pay any tax.
However, you may have to pay tax if you get any other income
this financial year, such as salary or wages.
If you think you will have to pay tax this year, you can ask us
to deduct tax instalments from your payment. You can change
this at any time.
If you are not sure how much tax to have taken out of your
payment, contact the Australian Taxation Office.
Do you want tax taken out of your payment?
No
Go to next question
Yes
Enter the amount OR percentage of tax you want taken
out per fortnight.
Amount
Percentage (%)
(must be in whole dollars)
of taxable payment
$
.00 per fortnight OR
% per fortnight
In a home which is owned by a private
company or a private trust that you have
an interest in
Go to 108
In a home you (and/or your partner) own or
you own jointly with another person, this
can include:
• paying it off (mortgage)
• a caravan, transportable home or boat
Go to 86
In a hospital or home for people with
disabilities
Go to 100
In accommodation which you (and/or your
partner) have the right to use for life
Go to 93
In public housing (e.g. housing owned
by the Housing Authority. This does not
include paying rent to a Community
Housing organisation.)
Go to 90
In a place where you (and/or your partner)
pay private rent (this includes site or
mooring fees)
Go to 98
In a boarding house/hostel/private hotel
Go to 100
In accommodation where you pay no rent
Go to 107
Other (e.g. this could be where you (and/or
your partner) do not have a fixed address)
Give details
below
Go to 98
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86 Is the home you (and/or your partner) own on a block of land
94 Tick which option describes how you (and/or your partner)
obtained a life interest in a home without any exchange of money
or transfer of assets:
Inherited the life interest
Go to 108
larger than 2 hectares (5 acres)?
No
Go to next question
Yes
You will need to complete and attach a Real
estate details form (Mod R). If you do not have
this form, go to our website
humanservices.gov.au/forms or call us on
136 150.
Go to 88
Go to 108
Have a formal agreement documenting
your right to accommodation for life
www.
Go to 98
Have an informal arrangement with
children to live at their home and pay rent
Go to 108
Informal arrangement, no rent paid
Other
87 Does the property that you (and/or your partner) live on have
Give details
below
more than one title document?
Go to next question
No
Yes
You will need to complete and attach a Real
136 150.
Go to 98
www.
95 What date did you (and/or your partner) make this
payment/transfer?
88 Is any part of the home property used for income producing
/
/
purposes?
Do NOT include rent from boarders or lodgers.
96 Details of the payment/transfer
How much did you (and/or your partner) pay?
Go to next question
No
Yes
$
You will need to complete and attach a
Business details form (Mod F) and a Real
these forms, go to our website
136 150.
AND/OR
What assets were transferred?
www.
89 Do you pay site, ground or mooring fees for the home you own
Market value of assets transferred?
(this could be for a caravan, transportable home or boat)?
No
Go to 108
Yes
Go to 98
$
97 Details of the person or organisation the payment/transfer was
made to
Full name (of the person or organisation)
90 Are you (and/or your partner) the primary tenant(s)?
That is, your (and/or your partner’s) name is on the tenancy
agreement (lease) with the public housing authority.
No
Go to next question
Yes
Go to 108
Address
91 Does the primary tenant pay rent at the market rate?
No
Go to next question
Not sure
Go to next question
Yes
Postcode
98 What type of accommodation do you (and your partner) live in?
Go to 99
Private house or townhouse/unit/flat
92 Do you (and/or your partner) live with the primary tenant AND
your (and/or your partner’s) income has been taken into account
by the public housing authority when calculating the rent?
No
Yes
Community housing
Defence housing
Caravan/cabin/mobile home
Go to 108
Go to 99
Boat
Boarding house/hostel/private hotel
Other
93 Did you (and/or your partner) pay a sum of money and/or transfer
assets to another person in return for this accommodation for life?
No
Go to next question
Yes
Go to 95
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Go to next question
Go to next question
16 of 35
Go to 100
Give details below
99 Do you (and your partner) share your accommodation with
100 Do you (and/or your partner) pay board and/or lodgings?
other people?
Board means you (and/or your partner) are provided with some
regular meals.
Lodgings means no meals are provided to you (and/or your
partner).
Sharing your accommodation means that you have the right to
use a kitchen, bedroom or bathroom with one or more persons.
This includes ALL family members (except children which you
are paid family assistance for), people who regularly stay at
your accommodation and people who work away from home
(e.g. truck drivers, miners, flight attendants, fishermen,
members of the armed forces).
No
Go to next question
Yes
Give details below
No
Go to 102
Yes
Go to next question
101 Can you separate the amounts you (and/or your partner) pay for
1 Person’s name
board and/or lodgings?
No
Total board and lodgings charged per day,
week, fortnight, 4 weeks or calendar month
Age
$
When did they move in?
/
Relationship to you
Yes
Amount paid for board (meals) per day, week,
fortnight, 4 weeks or calendar month
/
Their share of the rent/lodgings
$
$
Do they own the home?
No
per
2 Person’s name
per
Yes
per
Amount paid for lodgings (accommodation only)
per day, week, fortnight, 4 weeks or calendar month
$
Age
per
Go to 103
/
Relationship to you
102 How much do you (and/or your partner) pay per day, week,
/
$
per
fortnight, 4 weeks or calendar month (e.g. rent, maintenance
or site fees)?
No
3 Person’s name
Yes
This would be the total you (and/or your partner) pay for the
property minus any subsidy/rebate or contribution from
another person or organisation.
Age
$
/
Relationship to you
103 When did you (and/or your partner) start paying this amount?
/
$
per
No
per
/
/
Yes
104 Do you (and your partner) live in a boarding house, hostel, private
4 Person’s name
/
Relationship to you
/
per
No
Yes
Go to next question
Yes
Go to 106
per day, week, fortnight, 4 weeks or calendar month?
per
If you share with more than 4 people, attach a separate sheet
with details.
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No
105 What is the total amount of rent charged for the property
$
hotel, hospital or disability housing?
Age
17 of 35
106 Details of your landlord, authorised agent or person you (and/or
your partner) pay rent to
Full name
The current market value of an item is what you would get
if you sold it. It is not the replacement or insured value.
Include:
• all furniture (including soft furnishings such as curtains),
antiques and works of art
• electrical appliances such as televisions and fridges
• jewellery for personal use and hobby collections
(e.g. stamps, coins).
Do NOT include:
• fixtures such as stoves and built-in items.
Address
Postcode
Contact phone number
(
What is your estimate of the current market value of your (and/or
your partner’s) household contents and personal effects?
)
107 Do you (and/or your partner) have a current lease or tenancy
agreement with written evidence of the CURRENT amount of
rent, fees, lodgings or board and lodgings you (and/or your
partner) pay?
Current market value
Amount owed
$
$
Your share
% Partner’s share
%
Go to next question
No
Yes
110 Do you (and/or your partner) own, partly own or have a financial
Attach a full copy of your signed lease or
tenancy agreement.
interest in any motor vehicles, motor cycles or trailers?
Go to next question
No
Yes
Assets, Income and other financial information
Give details below
1 Type of asset (e.g. car)
Make (e.g. Ford)
108 In the last 14 days:
• have you (and/or your partner) claimed or been paid a
Centrelink payment, and
• did you (and/or your partner) provide us with your assets,
income and other financial information details and those
details have not changed?
No
Go to next question
Not sure
Go to next question
Yes
Model (e.g. Focus)
Amount owed
$
$
Your share
Go to 152
Year
2 Type of asset (e.g. car)
% Partner’s share
Make (e.g. Holden)
Model (e.g. Astra)
Year
Amount owed
$
$
Your share
%
% Partner’s share
%
If you (and/or your partner) have more than 2 motor vehicles,
motor cycles or trailers, attach a separate sheet with details.
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111 Do you (and/or your partner) own, partly own or have a financial
114 Give details below of any OTHER accounts held by you (and/or
interest in any boats or caravans/motor homes?
your partner) in banks, building societies or credit unions.
Do NOT include a boat or caravan that is your principal home.
No
Go to next question
Yes
Give details below
1 Type of asset (e.g. boat)
Make (e.g. Quintrex)
Model (e.g. Coastrunner)
Year
Amount owed
$
$
Your share
Include savings accounts, cheque accounts, term deposits, joint
accounts, accounts you hold in trust or under any other name,
or money held in church or charitable development funds.
Accounts and term deposits outside Australia should be
included, with the current balance in the type of currency in
which it is invested. We will convert this into Australian dollars.
Do NOT include shares, managed investments or an account
used exclusively for funding from the National Disability
Insurance Scheme.
Attach proof of all account balances (e.g. ATM slips,
statements, passbooks). Copies can be provided.
1
% Partner’s share
%
2 Type of asset (e.g. caravan) Make (e.g. Jayco)
Account number
card number)
Model (e.g. Heritage)
Branch number (BSB)
Year
Type of account
Amount owed
$
$
Your share
% Partner’s share
%
Currency if not AUD
If you (and/or your partner) have more than 2 boats, caravans
or motor homes, attach a separate sheet with details.
Your share
%
Partner’s
share
%
%
Partner’s
share
%
2
112 Do you (and/or your partner) have an interest in any other real
estate in and/or outside Australia?
Go to 114
No
Yes
Go to next question
Account number
card number)
Branch number (BSB)
113 How many other properties in and/or outside Australia do you
Type of account
(and/or your partner) own or have an interest in?
You will need to complete and attach a Real estate
details form (Mod R) for each property. If you do not have
humanservices.gov.au/forms or call us on 136 150.
Currency if not AUD
www.
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Your share
115 Do you (and/or your partner) have a life insurance policy that can
Continued
be cashed in?
3
Include:
• policies with a surrender value (e.g. whole of life, paid up
and endowment policies).
Do NOT include:
• friendly society bonds or life insurance bonds
• details of home, contents, car, mortgage or similar policies.
Account number
card number)
Branch number (BSB)
Type of account
No
Go to next question
Yes
Give details below
Attach the policy document and the latest
statement for each policy.
Currency if not AUD
Your share
%
Partner’s
share
1 Name of insurance company
%
4
Policy number
Account number
card number)
$
Your share
Type of account
Policy number
Your share
Currency if not AUD
%
Partner’s
share
%
%
Partner’s
share
%
5
Account number
card number)
Branch number (BSB)
Type of account
Currency if not AUD
If you (and/or your partner) have more than 5 accounts, attach
a separate sheet with details.
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%
Surrender value
$
Your share
% Partner’s share
2 Name of insurance company
Branch number (BSB)
Your share
Surrender value
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% Partner’s share
If you (and/or your partner) have more than 2 insurance
policies, attach a separate sheet with details.
%
116 Do you (and/or your partner) have any bonds or debentures?
117 Do you (and/or your partner) have any funeral bonds/funeral
investments?
Bonds refer to government and semi-government bonds.
Include:
• investments in and/or outside Australia.
Bonds or debentures outside Australia should be included, with
the current balance in the type of currency in which it is
invested. We will convert this into Australian dollars.
Do NOT include:
• friendly society bonds, funeral bonds or life insurance bonds
• accommodation bonds for residing in an aged care facility.
No
Go to next question
Yes
Give details below
Including a pre-paid funeral.
No
Go to 119
Yes
Give details below
1 Name of company
Name of product
Attach a document which gives details for each
bond or debenture.
1 Name of company
APIR code
Purchase price incl.
instalments but not interest
Current value
as per latest statement
Your share
$
Type of investment
Partner’s share
%
%
2 Name of company
Current amount invested
Currency if not AUD
Name of product
Your share
% Partner’s share
%
2 Name of company
Type of investment
APIR code
Purchase price incl.
instalments but not interest
Current value
as per latest statement
Your share
$
Currency if not AUD
Partner’s share
%
%
If you (and/or your partner) have more than 2 funeral bonds/
funeral investments, attach a separate sheet with details.
Your share
% Partner’s share
%
3 Name of company
118 Have you (and/or your partner) a contract to have funeral services
provided for which an agreed sum has already been paid to the
provider or used to buy funeral bonds assigned to the provider?
No
Type of investment
Yes
Your share
Currency if not AUD
% Partner’s share
%
If you (and/or your partner) have more than 3 bonds or
debentures, attach a separate sheet with details.
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Go to next question
Attach a copy of each contract.
119 Do you (and/or your partner) have money on loan to another
120 Do you (and/or your partner) own any shares, options, rights,
person or organisation?
Include all loans, whether they are made to family members,
other people or organisations or trusts.
Do NOT include loans to get accommodation in a hostel.
No
Go to next question
Yes
Give details below
Attach a document which gives details for each
loan (if available).
1 Who did you lend the money to?
convertible notes or other securities LISTED on an Australian
Stock Exchange (e.g. ASX, NSX, APX or Chi-X) or a stock
exchange outside Australia?
Include shares traded in exempt stock markets.
Do NOT include:
• managed investments
• investments purchased with a margin loan.
No
Go to next question
Yes
Give details below
Attach the latest statement for each share
holding.
Date lent
/
Amount lent
/
Current balance on loan
1 Name of company
$
Lent by you
$
%
Lent by
your partner
%
Number of shares or
other securities
ASX code (if known)
Country if not Australia
Your share
Partner’s share
%
Date lent
/
Amount lent
/
2 Name of company
$
Lent by you
$
%
%
Lent by
your partner
%
Number of shares or
other securities
ASX code (if known)
Your share
Partner’s share
%
Date lent
/
Amount lent
/
$
3 Name of company
$
Lent by you
%
%
Lent by
your partner
%
If you (and/or your partner) have more than 3 loans, attach a
separate sheet with details.
Number of shares or
other securities
ASX code (if known)
Your share
Partner’s share
%
%
If you (and/or your partner) have more than 3 share holdings,
attach a separate sheet with details.
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121 Do you (and/or your partner) own any shares, options or rights in
122 Do you (and/or your partner) have any managed investments in
PUBLIC companies, NOT listed on a stock exchange?
and/or outside Australia?
Do NOT include:
• managed investments
• investments purchased with a margin loan.
No
Go to next question
Yes
Give details below
Attach the latest statement detailing your share
holding for each company (if available).
1 Name of company
Type of shares
Number of shares
Your share
$
Include:
• investment trusts
• personal investment plans
• life insurance bonds
• friendly society bonds.
Do NOT include:
• conventional life insurance policies
• funeral bonds, superannuation or rollover investments.
APIR code – is commonly used by fund managers to identify
individual financial products.
No
Go to next question
Yes
Give details below
Attach a document which gives details
(e.g. certificate with number of units or
account balance) for each investment.
Partner’s share
%
%
1 Name of company
2 Name of company
Type of shares
$
Name of product
(e.g. investment trust)
Type of product/option
(e.g. balanced, growth)
Number of units
APIR code (if known)
Currency if not AUD
Number of shares
Your share
Partner’s share
%
%
If you (and/or your partner) have more than 2 share holdings,
$
Your share
% Partner’s share
%
2 Name of company
Name of product
(e.g. investment trust)
Type of product/option
(e.g. balanced, growth)
Number of units
Currency if not AUD
$
Your share
% Partner’s share
If you (and/or your partner) have more than 2 managed
investments, attach a separate sheet with details.
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%
123 Do you (and/or your partner) own any managed investments or
securities purchased with a margin loan?
No
Go to next question
Yes
Give details below
124 Continued
3 What you gave away or sold for less than its market value
(e.g. money, car, second home, land, farm)
Attach the latest statement detailing your
margin loan(s) for each investment.
Date given or sold
/
1 Name of margin loan company
What it was worth
/
$
Your share
What you got for it
Partner’s share
%
$
%
Current portfolio
Was this gift to a Special Disability Trust (SDT)? No
Current margin loan balance
Your share
If you (and/or your partner) have given away or sold for less
than its market value more than 3 items, attach a separate
sheet with details.
$
Partner’s share
%
%
2 Name of margin loan company
Yes
125 In the last 12 months have you (and/or your partner) borrowed
an amount which is secured against your home?
Current portfolio
Current margin loan balance
Your share
$
Partner’s share
%
%
If you (and/or your partner) have more than 2 margin loans,
Include:
• Home Equity Conversion Loan
• Reverse Equity Mortgage.
Do NOT include:
• a mortgage taken out to purchase your home.
No
Go to next question
Yes
Give details below
Attach a copy of the loan agreement or
contract.
124 In the last 5 years have you (and/or your partner) given away,
sold for less than their market value, or surrendered a right to,
any cash, assets, property or income?
Name of the organisation agreement entered into with
Include forgiven loans and shares in private companies.
Address of the organisation
No
Go to next question
Yes
Give details below
Postcode
Entered into by:
Date given or sold
/
/
What you got for it
What it was worth
Partner’s share
%
$
%
Yes
Date given or sold
/
/
What you got for it
$
What it was worth
$
Your share
Partner’s share
%
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Your partner
If you (and/or your partner) have more than 2 margin loans,
$
Your share
You
%
Yes
24 of 35
YOU should answer this question ONLY if you are over age
pension age.
YOUR PARTNER should answer this question ONLY if they are
over age pension age.
From 1 July 2017, the qualifying age for Age Pension will
increase from 65 years to 65 years and 6 months. The
qualifying age will then rise by 6 months every 2 years,
reaching 67 years by 1 July 2023. See table below.
Date of birth
Qualifying age at
1 July 1952 to 31 December 1953
1 January 1954 to 30 June 1955
1 July 1955 to 31 December 1956
From 1 January 1957
65 years and 6 months
66 years
66 years and 6 months
67 years
Do you (or your partner) have any money invested in
superannuation where the fund is still in accumulation phase and
not paying a pension?
Include:
• superannuation funds such as, retail, industry, corporate or
employer and public sector
• retirement savings accounts
• Self Managed Superannuation Funds (SMSF) and small
APRA Funds (SAF) if the funds are complying.
No
Go to next question
Yes
Give details below
An income stream product is a regular series of payments
which may be made for a lifetime or a fixed period by:
• a financial institution
• a retirement savings account
• a superannuation fund
• a Self Managed Superannuation Fund (SMSF)
• a small APRA Fund (SAF).
Types of income streams include:
• account-based pension (also known as account-based
income stream or allocated income stream)
• market-linked pension (also known as term allocated
pension)
• Annuities
• defined benefit pension (e.g. ComSuper pension, State
Super pension)
• superannuation pension (non-defined benefit).
Do you (and/or your partner) receive income from any income
stream products?
No
Go to next question
Yes
Give details below
You will need to attach a schedule, Details of
income stream product form (SA330) or a
similar schedule, for each income stream
product. The form or similar schedule must be
completed by your product provider or the
trustee of the Self Managed Superannuation
Fund (SMSF) or small APRA Fund (SAF) or the
SMSF administrator.
If you do not have this form, go to our website
136 150.
Attach the latest statement for each
superannuation investment. If you have a
SMSF or SAF, attach the financial returns and
member statement for the fund.
1 Name of product provider/SMSF/SAF
1 Name of institution/fund manager
Type of income stream
Name of fund
Date of joining/investment
/
Owned by:
www.
Product reference number
/
$
You
Your partner
Commencement date
/
Owned by:
You
Your partner
2 Name of institution/fund manager
2 Name of product provider/SMSF/SAF
Name of fund
Type of income stream
Date of joining/investment
/
Owned by:
/
$
You
Your partner
Product reference number
If you (and/or your partner) have more than 2 superannuation
investments, attach a separate sheet with details.
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Commencement date
/
Owned by:
25 of 35
You
/
/
Your partner
If you (and/or your partner) have more than 2 income stream
products, attach a separate sheet with details.
128 Do you (and/or your partner) have any money invested in, or do
129 Do you (and/or your partner) have any other assets (in or outside
you (and/or your partner) receive income from, any other
investments not declared elsewhere on this form?
Australia) that you have not already advised us about on this form?
Include taxi plates, time shares, racehorses, greyhounds,
travellers cheques, cyber currency (e.g. bitcoin), collectables
(e.g. stamps, coins, wine, art, antiques), commercial licences
(e.g. fishing, hunting).
Do NOT include an account used for funding from the National
Disability Insurance Scheme.
Include:
• all investments from outside Australia (including
superannuation) not declared elsewhere on this form
Do NOT include:
• income from real estate in or outside Australia, private
trusts, private companies or business
• social security payments
• an account used exclusively for funding from the National
Disability Insurance Scheme.
No
Go to next question
Yes
Give details below
No
Go to next question
Yes
Give details below
1 Description of asset
Attach a document which gives details for
each investment.
1 Type of investment
Amount owed
Currency if not AUD
Your share
Partner’s share
%
2 Description of asset
Name of organisation/company
Current value
of investment
Income received
in last 12 months
Currency if not AUD
Your share
Amount owed
Currency if not AUD
Your share
Partner’s share
%
Partner’s share
%
%
%
If you (and/or your partner) have more than 2 other assets,
130 Do you (and/or your partner) receive payments from an income
Current value
of investment
%
protection policy?
Income received
in last 12 months
No
Go to next question
Yes
Give details below
Attach the policy document and the latest
statement for this policy.
Currency if not AUD
Your share
Partner’s share
%
%
131 Do you (and/or your partner) CURRENTLY receive any income
from work other than self employment?
GROSS income from eomployment includes amounts
voluntarily salary sacrificed into superannuation and the value
of employer provided fringe benefits.
Current value
of investment
Income received
in last 12 months
Currency if not AUD
Your share
%
If you (and/or your partner) have more than 3 investments,
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Go to 133
Give details in the next column
Attach payslip(s) for the last 8 weeks from
each employer.
Partner’s share
%
No
Yes
26 of 35
131 Continued
132 Do you (and/or your partner) get any fringe benefits provided by
an employer (e.g. use of a car as part of a salary package,
rent/mortgage paid)?
1 Employer’s name
Fringe benefits – means a benefit received as part of earned
income but not as a wage or salary.
Address
Go to next question
No
Yes
Attach details that indicate the type of
fringe benefit and its value, and whether or
not the amount provided is ‘grossed up’ or
not ‘grossed up’.
Postcode
Phone number
(
)
133 In the last 12 months, have you (and/or your partner) stopped
Australian Business Number (ABN)
working for any employers (including self-employment)?
Who works for this employer?
You
Is this work:
Full-time
Seasonal
Part-time
Your partner
No
Go to next question
Yes
Give details below
Attach documents which confirm that you
stopped work (e.g. letter from employer or
Employment Separation Certificate form
(SU001)). If you do not have this form, go to
our website humanservices.gov.au/forms
or call us on 136 150.
Casual
Personnel, service or
clock-card number
www.
Hours worked per fortnight
GROSS amount earned per
fortnight before tax and
other deductions
Is this the usual wage?
per fortnight
$
per fortnight
No
Yes
1 Employer’s name
Address
2 Employer’s name
Postcode
Address
Phone number
(
Who worked for this employer?
Postcode
Phone number
(
You
Your partner
2 Employer’s name
)
Address
Who works for this employer?
You
Is this work:
Full-time
Seasonal
Part-time
Your partner
Postcode
Casual
Phone number
Personnel, service or
clock-card number
(
Hours worked per fortnight
GROSS amount earned per
fortnight before tax and
other deductions
Is this the usual wage?
per fortnight
$
No
per fortnight
Yes
If you (and/or your partner) currently get income from more
than 2 jobs, attach a separate sheet with details.
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)
27 of 35
)
Who worked for this employer?
You
Your partner
If you (and/or your partner) stopped working for more than
2 employers, attach a separate sheet with details.
134 In the last 12 months, have you (and/or your partner) received or
134 Continued
do you (and/or your partner) expect to receive, any leave
entitlement payments from an employer you have worked for?
2 Type of leave entitlement payment
Include:
• annual leave
• maternity leave
• long service leave or sick leave you received when you
stopped work
• redundancy payments
• entitlements that you cashed in before you stopped work
• money in a long-service leave fund or scheme that you
have not cashed in.
Number of working days
covered by the payment
$
Date paid or date payable
/
Yes
/
Leave entitlement for
You
Your partner
Employer’s details
Name of business
Go to next question
No
Amount (before tax and
other deductions)
Attach documents which confirm each leave
entitlement payment (e.g. letter from
employer or Employment Separation
Certificate form (SU001)). If you do not have
136 150.
Address
www.
1 Type of leave entitlement payment
Postcode
Number of working days
covered by the payment
Phone number
Amount (before tax and
other deductions)
(
$
Date paid or date payable
/
/
)
Job description
Leave entitlement for
You
Your partner
If you (and/or your partner) have more than 2 entitlements,
Employer’s details
Name of business
135 Have you (and/or your partner) received a redundancy payment
in the last 2 years?
No
Go to next question
Address
Yes
Attach documents which confirm any
redundancy payment (e.g. letter from
employer or Employment Separation
Certificate form (SU001)). If you do not have
136 150.
www.
Postcode
Phone number
(
)
Job description
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139 Do you receive payments from sources other than Centrelink
Seasonal work is work that is available for part or parts of
the year at approximately the same time each year.
Contract work is any intermittent work that is performed
under a contract for a specific function and/or period including
sub-contract work.
Intermittent work is work that is available from time to time,
can reasonably be predicted to end or not be available for a
period, is less than a year in duration and does not accrue
leave entitlements.
In the last 6 months have you (and/or your partner) done any
seasonal, contract, or intermittent work?
income support payments?
For example:
• a payment from Department of Veterans' Affairs (DVA), or
• New Enterprise Incentive Scheme (NEIS) Allowance, or
• Community Development Employment Projects (CDEP)
wages.
No
Go to next question
Yes
Give details below
Attach a letter or other document(s) that shows
the reference number and details for each
payment (other than payments made by us).
Go to next question
No
Yes
Seasonal, Contract and Intermittent Work
Details form (SU496). If you do not have this
form, go to our website
136 150.
1 Type of payment
www.
Who pays it?
137 In the last 12 weeks have you become voluntarily unemployed?
No
Go to next question
Yes
Date employment ceased
Int
/
Reference number (if known)
Date commenced (if known)
/
Paid to:
/
You
/
Your partner
2 Type of payment
Reason you became voluntarily unemployed
Who pays it?
Reference number (if known)
138 In the last 12 weeks have you been dismissed from employment
due to misconduct?
No
Go to next question
Yes
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Paid to:
Date employment ceased
Int
/
/
You
/
Your partner
If you (and/ or your partner) receive more than 2 payments,
/
29 of 35
140 Do you (and/or your partner) receive payments from an authority
141 Do you (or your partner) receive money from any boarders or
or agency outside Australia?
lodgers living with you?
Include pensions from other countries, benefits, allowances,
superannuation, compensation and war related payments.
Note: You must include details of pensions, allowances and
other payments even if they are not taxable in the country of
payment.
No
Go to next question
Yes
Give details below
Include boarders or lodgers who live with you or in
accommodation at the property you live in (e.g. granny flat).
Do NOT include immediate family members (son, daughter,
parent).
No
Go to next question
Yes
Give details below
1 Name of person
Attach a document from the issuing authority
or agency which gives details including the
amount in the foreign currency (e.g. latest
pension certificate) for each payment.
Number of meals
you provide each day
Relationship to you
1 Type of payment
Amount paid per fortnight
Country which pays it?
Date started paying
/
$
Your share
/
% Partner’s share
%
Authority or agency which pays it?
2 Name of person
/
/
Paid to:
You
Number of meals
you provide each day
Your partner
Relationship to you
2 Type of payment
Amount paid per fortnight
Date started paying
/
$
Your share
% Partner’s share
/
%
If you (and/or your partner) receive money from more than
2 people living with you, attach a separate sheet with details.
/
/
Paid to:
You
Your partner
3 Type of payment
/
/
Paid to:
You
Your partner
If you (and/or your partner) receive more than 3 payments from
an authority or agency outside Australia, attach a separate sheet
with details.
SC277.1501
30 of 35
You may be, or have been involved in a trust as:
• a trustee
• an appointor
• a beneficiary
OR have:
• made a loan to a private trust
• made a gift of cash, assets, or private property to a private
trust in the last 5 years
• relinquished control of a private trust in the last 5 years
• a private annuity
• a life interest
• an interest in a deceased estate.
A private trust includes a non-complying Self Managed
Superannuation Fund or a non-complying Small APRA Fund.
Are you or have you (and/or your partner) been involved in a
private trust in any of the ways detailed above?
No
Go to 147
Yes
Go to next question
143 Is the private trust now vested?
No
149 Have you (and/or your partner) made any type of gift involving a
private company (either registered or deregistered) in the last
5 years?
Go to next question
Yes
You will need to provide evidence of the
vesting.
Go to next question
No
Yes
150 Have you told us about this private company before?
144 Have you (and/or your partner) made any type of gift involving a
No
private trust (either active or vested) in the last 5 years?
No
Go to 147
Yes
Go to next question
Private Company form (Mod PC). If you do not
have this form, go to our website
136 150.
Go to next question
www
145 Have you told us about this private trust before?
No
Go to next question
Yes
Go to 147
Yes
151 Are you (and/or your partner) involved in any type of business?
Include:
• farming
• self-employed
• sole trader
• partnership
• sub-contractor.
146 Is the private trust a Special Disability Trust (SDT)?
No
Private Trust form (Mod PT). If you do not
have this form, go to our website
136 150.
www.
Yes
www.
Go to next question
No
Special Disability Trust form (Mod SDT).
136 150.
Yes
Go to next question
Business details form (Mod F). If the business
owns real estate you will also need to complete
and attach a Real estate details form (Mod R)
for each property. If you do not have these
forms, go to our website
136 150.
www.
You may be, or have been in the last 5 years:
• a director of a company
• a shareholder of a company
OR have:
• made a loan to a private company
• transferred shares in a private company
• made a gift of cash, assets or property to a private
company.
Are you or have you (and/or your partner) been involved with a
private company in any of the ways detailed above?
No
Go to 151
Yes
Go to next question
Have you (or your partner) ever CLAIMED or are you (or your
partner) ABLE TO CLAIM compensation, insurance and/or
damages?
148 Is the private company now deregistered with the Australian
Securities and Investments Commission (ASIC)?
No
Yes
SC277.1501
Include:
• workers’ compensation/damages as a result of a work injury
• third party damages as a result of a motor vehicle accident
• personal accident and sickness insurance or income
replacement insurance
• sporting injury compensation
• public liability compensation
• medical negligence compensation
• damages paid to victims of crime or as a result of criminal
injuries.
No
Go to next question
Yes
You will need to provide evidence of
deregistration.
Go to next question
31 of 35
Go to next question
Compensation and damages form (Mod C).
136 150.
www.
153 Are you (and/or your partner) RECEIVING or have you (and/or
156 Do you (and/or your partner) receive any payments from other
your partner) EVER BEEN PAID compensation, insurance and/or
damages?
No
Go to next question
Yes
Compensation and damages form (Mod C).
136 150.
www.
154 Do you have a disability that prevents you from using public
transport without substantial assistance for the next 12 months
or longer, or need to travel to and from your home as part of your
work, training or job seeking?
sources that you have not already advised us about on this form?
Include:
• gratuities
• match or sporting payments
• other income or payment from other countries
• payment in kind, such as non-monetary payments for services
• scholarships, educational assistance or allowance
• any other income.
Do NOT include funding from the National Disability Insurance
Scheme.
No
Go to next question
Yes
Give details below
Attach the most recent statement/certificate
that gives details for each type of payment.
You may qualify for an additional payment of Mobility
Allowance.
No
1 Type of payment
Go to next question
Yes
Claim for Mobility Allowance form (MA001).
humanservices.gov.au/mobilityallowance or
call us on 136 150.
Who pays it?
www.
Amount per fortnight
155 In the last 12 months, have you (or your partner) received a lump
sum payment that you have not already advised on this form?
Do NOT include:
• compensation, insurance or damages lump sum payments
• funding from the National Disability Insurance Scheme.
No
Go to next question
Yes
Give details below
Your share
$
%
%
2 Type of payment
Who pays it?
Your share
$
1 Type of lump sum
Partner’s share
Partner’s share
%
%
3 Type of payment
Who paid it?
Who pays it?
Amount paid
Date paid
$
Who received this lump
sum payment?
/
You
/
Your partner
$
Partner’s share
%
If you (and/or your partner) receive more than 3 types of
payments, attach a separate sheet with details.
If you (and/or your partner) have received more than 1 lump
sum payment, attach a separate sheet with details.
SC277.1501
Your share
32 of 35
%
157 Are you a single principal carer who is currently undertaking
161 Have you stopped or completed primary or full-time secondary
studies?
full-time or part-time study?
You may qualify for an additional payment of Pensioner
Education Supplement.
Go to next question
No
Yes
No
Go to next question
Yes
Give details below
Date stopped studying
Claim for Pensioner Education Supplement
(PES) form (SY004). If you do not have this
form, go to our website
humanservices.gov.au/pensionereducation
or call us on 136 150.
/
/
Name of School/College/Campus
(including Australian Technical College)
www.
158 Are you under 20 years of age?
No
Go to 162
Yes
Go to next question
Checklist
162 Which of the following forms, documents and other attachments
are you (and/or your partner) providing with this form?
If you are not sure, check the question to see if you should attach
the documents.
159 Are you currently studying?
No
Go to next question
Yes
Give details below
Date started study
/
Where you are asked to supply documents, please attach
original documents.
/
Proof of identity for you (and your partner)
(refer to the Information Booklet for more information)
Type of study
Authorising a person or organisation to enquire or act
on your behalf form (SS313)
(If you answered Yes at question 15)
Primary education
Full-time secondary study
Proof of Australian residence status
(If you answered No at question 18 and/or question 52)
Indicate if you are studying by one of the following
methods
Tick box if it
applies to you
Documents showing balances for bank, building society and
credit union accounts
(Required at question 30)
Home schooling
Special education
Dependent children proof of birth
(If you answered No at question 78)
Study outside Australia
160 Have you been granted an exemption from studying by your state
Real estate details form (Mod R)
(If you answered Yes at question 86 and/or question 87)
or territory education authority?
No
Go to next question
Yes
Give details below
Details of additional children
Business details form (Mod F) and
Full copy of your signed lease or tenancy agreement
(if you answered Yes at question 107)
Start date
/
Documents showing balances for bank, building society and
credit union accounts
(Required at question 114)
Date this circumstance
will cease
/
/
Insurance policy documents and latest statements
/
Investment bond/debenture documents
Funeral bond contract(s)
Money on loan documents (if available)
SC277.1501
33 of 35
162 Continued
162 Continued
Private Company form (Mod PC)
Latest statement for each shareholding LISTED
on a stock exchange
Business details form (Mod F) and
Latest statement for each shareholding NOT Listed
on a stock exchange
Compensation and damages form (Mod C)
(If you answered Yes at question 152 and/or question 153)
Managed investment certificates or similar documents
Claim for Mobility Allowance form (MA001)
Latest statement for margin loans for each investment
Documents with details of other payments
Copy of the loan agreement or contract
Claim for Pensioner Education Supplement form (SY004)
Latest statements for approved deposit funds, deferred
annuities, rollover funds and superannuation funds, tax returns
and member’s statements for SMSF and SAF funds, and latest
council rates notices for real estate held by those funds
Latest schedules for income stream products OR
Details of income stream product form (SA330)
Questions continue
Documents with details of investments
Income protection policy documents and latest statements
Payslip(s) for the last 8 weeks from each employer
Fringe Benefit details
Documents which confirm you stopped work OR
Employment Separation Certificate form (SU001)
Documents which confirm leave entitlement payment OR
Documents which confirm redundancy payment OR
Seasonal, Contract & Intermittent Work Details
form (SU496)
Letters/documents with details of other
Australian government payments
Documents with details of payments by authorities or agencies
outside Australia (If you answered Yes at question 140)
Evidence of the vesting of the private trust
Private Trust form (Mod PT)
Special Disability Trust form (Mod SDT)
Evidence of the deregistration of the private compnay
SC277.1501
34 of 35
163 IMPORTANT INFORMATION
Privacy and your personal information
Your personal information is protected by law, including the
Privacy Act 1988, and is collected by the Australian
Government Department of Human Services for the
assessment and administration of payments and services. This
information is required to process your application or claim.
Your information may be used by the department or given to
other parties for the purposes of research, investigation or
where you have agreed or it is required or authorised by law.
You can get more information about the way in which the
Department of Human Services will manage your personal
information, including our privacy policy at
humanservices.gov.au/privacy or by requesting a copy from
the department.
www.
Your (and your partner's) statement
164 Statement
This statement must be read and signed by you (and your
partner).
I declare that:
• the information I have provided in this claim is complete and
correct.
I understand that:
• giving false or misleading information is a serious offence.
• the Australian Government Department of Human Services
can make enquiries necessary to make sure I receive the
correct entitlement.
• I may be required to enter into an Employment Pathway Plan/
Individual Participation Plan with the Australian Government
Department of Human Services and will take all reasonable
steps to meet the terms of this Plan.
• I must notify the Australian Government Department of Human
Services of any changes to this information, within 14 days
of the change(s) occurring.
Your signature
Date
/
/
Partner’s signature
Date
/
/
OFFICE USE ONLY
CRN
Date of receipt
/
SC277.1501
35 of 35
/

Claim for Parenting Payment - Department of Human Services

Transcription

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