claim for parenting payment (sc277) · claiming parenting payment online is faster and easier....

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When to use this form This form is used to claim Parenting Payment.

Parenting Payment is paid to the principal carer of a child if:

• you are single and your youngest child is under 8 years of age , or• you are partnered and your youngest child is under 6 years of age.

What else you may need to provide

Online services

You may need to provide identity documents. For a list of acceptable documents, refer to Confirming your identity in the Information Booklet or go to www.humanservices.gov.au/identity

If you do not have a partner, you are required to complete and attach a Verification of Relationship Status form (SC321) with your Parenting Payment claim.

If you do not have this form, go to www.humanservices.gov.au/forms

You must return all supporting documents at the same time you lodge this claim form. If you do not return all documents, your claim may not be accepted. The only exception will be if you are waiting for medical evidence or other documents from a third party.

Claiming Parenting Payment online is faster and easier. 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.

You can update your Parenting Payment information using your Centrelink online account through myGov. For help, go to www.humanservices.gov.au/onlineguides

If you do not have a myGov account, you can create one at www.my.gov.au and link it to your Centrelink online account.

For more information Refer to Information you need to know about your claim for Parenting Payment (Ci008) (Information Booklet) at www.humanservices.gov.au/parentingpayment.

We can translate documents you need for your claim or payments for free.

To speak to us in other languages, call 131 202.

Note: Call charges may apply.

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.

Claim forParenting Payment (SC277)

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8 Your date of birth

/ /

6 Have you ever used or been known by any other name?

Include:• name at birth• maiden name• previous married name• Aboriginal or tribal name• alias• adoptive name• foster name.

10

9

Your postal address (if different to above)

Your permanent address

Postcode

Postcode

5 Your name

Other

Family name

First given name

Second given name

Mr Mrs MsMiss

7 Your genderMale

Female

1 Do you need an interpreter when dealing with us?This includes an interpreter for people who have a hearing or speech impairment.

Go to 4

Go to next question

No

No

Yes

Yes

Go to next question

Give details below

2 What is your preferred spoken language?

3 What is your preferred written language?

4 Are you the principal carer of a dependent child under 6 years (for partnered claimants) or under 8 years (for single claimants)?

You will not be entitled to Parenting Payment. Please call us on 136 150.

Go to next question

No

Yes

Note: If you are claiming Parenting Payment as a single claimant and your youngest child is aged 6 or 7 years, you will have Mutual Obligation Requirements. For information about Mutual Obligation Requirements, go to www.

humanservices.gov.au/parentingpayment

Personal details

1 Other name

Type of name (e.g. name at birth)

2 Other name

Type of name (e.g. maiden name)

If you have more than two other names, attach a separate sheet with details.

CLK0SC277 1809

Filling in this form

• Please use black or blue pen.• Print in BLOCK LETTERS.• Where you see a box like this Go to 5 skip to the question

number shown. You do not need to answer the questions in between.

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14

Are you of Australian South Sea Islander descent?

16

No

Yes

11If 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 www.

humanservices.gov.au/em or visit one of our service centres.

Please read this before answering the following question.

Home phone number

Your contact details

Is this a silent number?

Is this a silent number?

No

No

Yes

Yes

Whose name is the phone account in? My name

My partner’s name

Another name

Mobile phone number

Whose name is the mobile phone account in? My name

My partner’s name

Another name

Fax number

Work phone number

Alternative phone number

Email

@

( )

( )

( )

( )

12 Do you currently get another type of Social Security payment or Family Tax Benefit?

Go to next questionNo

Yes Your Centrelink Reference Number (if known)

13 Please read this before answering the following questions.

This question is voluntary 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.

Are you of Aboriginal or Torres Strait Islander Australian descent?If you are of both Aboriginal and Torres Strait Islander Australian descent, please tick both ‘Yes’ boxes.

No

Yes – Aboriginal Australian

Yes – Torres Strait Islander Australian

15 Do you want another person or organisation to enquire or act on your behalf when dealing with us?No Go to next question

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 www.humanservices.gov.au/nominees or call us on 136 150.

Residence details

17 Have you EVER travelled outside Australia, including short trips and holidays?

This question assists us to verify your Australian residence.

Year you last entered Australia

Passport number

Country of issue

What country are you currently living in?

The country of residence is where you normally live on a long term basis.

Australia

Other

Go to next question

Country of residence

No

Yes

Go to next question

Give details below

Please read this before answering the following questions.

This question is voluntary and will not affect your payment. If you do answer, the information will help us to continue to improve services to people of Australian South Sea Islander descent.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?

Go to 28


Yes

19 What is your country of birth?

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28 Please read this before answering the following question.

We need to know if you have lived in any countries other than Australia. ‘Lived’ means where you or your family made your home or spent a long period of time – it does not include places you visited for a holiday.

Have you EVER lived outside Australia for any period?Go to next question

If you need more space, attach a separate sheet with details.

List ALL countries you have lived in since birth and the date you started living in each country.

Include when you started living in AUSTRALIA.

Do NOT include short trips or holidays.

/ /

/ /

/ /

No

Yes

24 Did you start living in Australia before 1965?

No Go to next question

Yes Give details belowName 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?

20 What is your country of citizenship?

Australia Date citizenship granted

Go to next question

21 What type of visa did you arrive on?

New Zealand passport (Special Category visa)

Go to 23

Permanent Go to next question

Temporary Go to next question

Not sure Go to 23

22 Your visa details on arrival

Visa sub class Date visa granted

23 Has your visa changed since you arrived in Australia?


Yes Most recent visa details

Visa sub class Date visa granted

25 Are you a refugee or former refugee?No

Yes

26 Did your partner or either of your parents arrive on a refugee or humanitarian visa?No

Yes

27 Did someone provide you with an Assurance of Support for your migration to Australia?

No

Not sure

YesOther Give details below

Country of citizenship

Date citizenship granted

/ /

Country Date from

/ /

/ /

/ /

/ /

/ /

/ /

Payment details

29 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.Note: Payments cannot be made into an account used exclusively for funding from the National Disability Insurance Scheme.

Name of bank, building society or credit union

Branch number (BSB)

Account number (this may not be

your card number)

Balance of account

Account held in the name(s) of

$

Attach proof of account balances (e.g. statements, passbooks).

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Relationship status

30 Select ONE option below that best describes your current relationship status.

31 Do you live in the same home as your partner?Go to next question

Go to 43

No

Yes

Go to 43

32 Why are you not living with your partner?

Partner’s illnessYour illness

Partner in prisonPartner’s employment

Other Give details below

33 Period not living with your partner

From

To OR indefinite

/ /

/ /

34 Did your deceased partner ever live outside Australia?No

Yesint

35 Please give the following details about your deceased partner

Full Name

Date of birth

Go to 60

/ /

If you have ever been separated, list the date that you most recently reconciled with your partner.

Married Date married/ reconciled with your partner

/ /

Go to 31

Registered relationship(registered under state or territory law)

Date registered/ reconciled with your partner

/ /

Go to 31

Partnered

(living together in a relationship, including de facto)

Date you started your relationship/reconciled with your partner

/ /

Go to 31

Separated(previously in a marriage, registered or de facto relationship)

Date of last separation

/ /

Go to 36

Divorced Date of divorce

/ /

Go to 36

Widowed(previously in a marriage, registered or de facto relationship)

Date of partner’s death

/ /

Go to 34

Never married or lived with a partner

Go to 60

36 Your ex-partner’s family name

First given name

Second given name

37 Do you know if your ex-partner has been known by any other name(s)?

Other name(s)

No

Yes

Go to next question

Give details below

For example: Name at birth, name before marriage, previous married name, Aboriginal or tribal name, alias, adoptive name, foster name.


38 Do you live in the same home as your ex-partner?

No

Yes

Go to 40

Go to next question

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40

41

39

Your ex-partner’s current address (if known)

Do you think that you and your ex-partner will get back together?

Are you concerned about your safety if forms are issued to your ex-partner?

No

Yes

Both you and your ex-partner each need to complete and attach a separate Relationship details – Separated under one roof form (SS293).If you do not have this form, go to www.

humanservices.gov.au/forms Go to 41

Only you need to complete and attach a separate Relationship details – Separated under one roof form (SS293).If you do not have this form, go to www.

humanservices.gov.au/forms Go to 41

Postcode

No

Yes

Go to next question

Give details below

When will you get back together?

42 Are there any reasons for your separation that you would like to discuss with a social worker?

Go to 60No

Yes

Your partner’s name

Family name

First given name

Second given name

43

OtherMr Mrs MsMiss

44 Has your partner ever used or been known by any other name?

Go to next question

Give details below

No

Yes

1 Other name

Type of name (e.g. name at birth)

2 Other name

Type of name (e.g. maiden name)

45

46

Your partner’s genderMale

Female

Your partner’s date of birth

/ /

If your partner has more than two other names, attach a separate sheet with details.

Include:• name at birth• maiden name• previous married name• Aboriginal or tribal name• alias• adoptive name• foster name.

47 Does your partner currently get another type of Social Security payment or Family Tax Benefit?

Go to next question

Your partner’s Centrelink Reference Number (if known)

No

Yes

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48 Your partner’s permanent address

Postcode

49

50 Has your partner EVER travelled outside Australia, including short trips and holidays?

This question assists us to verify your partner’s Australian residence.

Year your partner last entered Australia

Passport number

Country of issue

51 Is your partner an Australian citizen who was born in Australia?

Go to 58

Go to next question

52 What is your partner’s country of birth?

No

Yes

Name of the ship or airline on which your partner arrived

Name of the place where your partner first arrived/disembarked

What was your partner’s name when they first arrived in Australia?

57

53

Did your partner start living in Australia before 1965?

What is your partner’s country of citizenship?Date citizenship granted

Go to next question

Give details below

Go to next question

55 What is your partner’s current type of visa?

New Zealand passport (Special Category visa)

Go to 58

Permanent

Temporary

Not sure

Go to next question

Go to next question

Go to 58

/ /

No

Australia

Yes

56 Your partner’s current visa detailsVisa sub class Date visa granted

/ /

What country is your partner currently living in?

Australia Go to next question

Other Country of residence

The country of residence is where your partner normally lives on a long term basis.


Go to next question

Give details below

Not applicable – never travelled to Australia

Yes

54 Has your partner ever lived in Australia?Go to 59

Go to next question

No

Yes


Date citizenship granted

/ /

Country of citizenship



We need to know if your partner has lived in any countries other than Australia. ‘Lived’ means where your partner or their family made their home or spent a long period of time – it does not include places you visited for a holiday.

Has your partner EVER lived outside Australia for any period?

Go to next question

List ALL countries your partner has lived in since birth and the date your partner started living in each country.

Include when you started living in AUSTRALIA.

Do NOT include short trips or holidays.

No

Yes

Country Date from

/ /

/ /

/ /

/ /

/ /

/ /

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6259 Do you give permission for your partner to make enquiries with us on your behalf?

You can change this authority at any time.No

Yes

60

61

Are you married, in a registered relationship or partnered (including de facto)?

Do you share your accommodation with anyone other than an immediate family member?

Go to next question

Go to 63

Go to 63

No

No

Yes

Yes

Living arrangements

Person 1

Give details below

Give details below

Have you and this person shared accommodation at another address?

Have you and this person previously lived together as a couple (e.g. married, partnered, de facto or in a registered relationship)?

Do you and this person share the parent/guardianship of any children?

Have you and this person ever had any joint financial commitments (e.g. joint bank account, mortgage or other loans)?

If you participate in activities jointly with this person, are you considered to be a couple?

No

No

No

No

No

Yes

Yes

Yes

Yes

Yes

SS293

SS284

SS284

SS284

Name Age

What is your relationship to this person?

Gender

Male Female / /

When did you start sharing with this person?

Are you concerned about your safety if forms are issued to this person?No

Yes

You need to complete and attach a Verification of Relationship Status form (SC321). If you do not have this form, go to www.

humanservices.gov.au/forms Go to next question

Your relationship status will need to be verified by an independent referee.If you answered Widowed at Question 30 and your partner died less than 2 years ago you are not required to complete the Verification of Relationship Status form (SC321) at this time.


We need full details about your living arrangements to work out your correct payment.The answers to these questions will help us decide if we need more information from you.

Include anyone who:• regularly stays any number of nights per week• uses your home as a base (e.g. truck drivers, miners,

flight attendants or members of the armed forces).Do NOT include immediate family members.

Give details of each person who shares your accommodation.

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Continued

If you share with more than three people, attach a separate sheet with details.

Continued

Person 2

Give details below

Give details below






No

No

No

No

No

Yes

Yes

Yes

Yes

Yes

SS293

SS284

SS284

SS284

Name Age


Gender

Male Female / /



Yes

Person 3

Give details below

Give details below






No

No

No

No

No

Yes

Yes

Yes

Yes

Yes

SS293

SS284

SS284

SS284

Name Age


Gender

Male Female / /



Yes

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If you have more than two dependent children, copy and attach pages (11 and 12) for each additional child before completing the detailsfor child 1.

63 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?

About your dependent children or students

64

65

66

67

68

69

Family name

First given name

Second given name

Child 1

Has this child ever been known by any other names?Go to next question

List the other names

No

Yes

Date of birth

What is this child’s country of birth?

/ /

GenderMale

Female

Does this child currently live with you?

Which of the following best describes your relationship to this child?

Passport number

Country of issue

Has this child EVER travelled outside Australia, including short trips and holidays?

This question assists us to verify this child’s Australian residence.


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.

ParentGrandparentStep-parentFoster carer


Does this child receive a payment from any Commonwealth, State or Territory Government?

Is this child 5 years of age or older?

Is this child in full-time education?

Does this child have any income?

Do you (and/or your partner) share the care of this child with another person? Do not include school/day care arrangements.

Go to next question

Go to 77

Go to next question

Go to next question

Give details below

Go to next question

Amount

What is the percentage of your (or your partner’s) care of this child?

No

No

No

No

No

No

Yes

Yes

Yes

Yes

Yes

Yes

%

$ per week

Year child last entered Australia


Go to next question

Give details below


Yes

70

71

72

73

74

75

76

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Child 1

Attach proof of birth (e.g. birth certificate) for this child if you have not previously provided it to us.

No

Yes

Go to 79 on page 15No

Yes

Do you have another dependent child?

Do you receive Family Tax Benefit for this child?

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 page

77

78

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Child 2

64

65

66

67

68

69

Family name

First given name

Second given name

Has this child ever been known by any other names?Go to next question

List the other names

No

Yes

Date of birth

What is this child’s country of birth?

/ /

GenderMale

Female

Does this child currently live with you?

Which of the following best describes your relationship to this child?

Passport number

Country of issue

Has this child EVER travelled outside Australia, including short trips and holidays?

This question assists us to verify this child’s Australian residence.


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.

ParentGrandparentStep-parentFoster carer


Does this child receive a payment from any Commonwealth, State or Territory Government?

Is this child 5 years of age or older?

Is this child in full-time education?

Does this child have any income?

Do you (and/or your partner) share the care of this child with another person? Do not include school/day care arrangements.

Go to next question

Go to 77

Go to next question

Go to next question

Give details below

Go to next question

Amount

What is the percentage of your (or your partner’s) care of this child?

No

No

No

No

No

No

Yes

Yes

Yes

Yes

Yes

Yes

%

$ per week

Year child last entered Australia


Go to next question

Give details below


Yes

70

71

72

73

74

75

76

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Child 2

Attach details of each additional child.

Go to next question


Yes

Do you have another dependent child?78

Attach proof of birth (e.g. birth certificate) for this child if you have not previously provided it to us.

No

Yes

Do you receive Family Tax Benefit for this child?77

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79 82

83

84

81

80

Please read this before answering the following questions. In the last 14 days:

Do you (and/or your partner) own a home but live elsewhere?

Which of the following best describes where you live?


Do you (and your partner) have a tax file number?

Tax details Accommodation

Go to next question

Not sure Go to next question

Go to 81

No

Yes

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.

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.

Have you (and your partner) given us your tax file number before?

Do you want tax taken out of your payment?

YouNo Please call us on 136 150.

Yes Your tax file number

Your partnerNo Please call us on 136 150.

Yes Your partner’s tax file number

Go to next question

Enter the amount OR percentage of tax you want taken out per fortnight.

No

Yes

Amount (must be in whole dollars)

$ .00 per fortnight

Percentage (%) of taxable payment

% per fortnightOR

• 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?

Go to next question


Go to 107

No

Yes

Go to next question

What is the reason you live away from the home you own?

No

Yes

Travelling away from your homeBeing cared for away from your home

Caring for someone away from your homeLiving away from home to study


In a home which is owned by a private company or a private trust that you have an interest in Go to 107

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

In a hospital or home for people with disabilities

In accommodation which you (and/or your partner) have the right to use for life

Other (e.g. this could be where you (and/or your partner) do not have a fixed address)

In a boarding house/hostel/private hotel

In accommodation where you pay no rent

In public housing (e.g. housing owned by the Housing Authority. This does not include paying rent to a Community Housing organisation.)

In a place where you (and/or your partner) pay private rent (this includes site or mooring fees)

Go to 85

Go to 99

Go to 92

Give detailsbelow

Go to 99

Go to 106

Go to 89

Go to 97

Go to 97

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85

86

Is the home you (and/or your partner) own on a block of land larger than 2 hectares (5 acres)?

Does the property that you (and/or your partner) live on have more than one title document?

93 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:No

No

Go to next question

Go to next question

Yes

Yes

You will need to complete and attach a Real estate details form (Mod R). If you do not have this form, go to www.humanservices.gov.au/forms or call us on 136 150.

Go to 87

You will need to complete and attach a Real estate details form (Mod R). If you do not have this form, go to www.

humanservices.gov.au/forms or call us on 136 150.

87

89

90

Is any part of the home property used for income producing purposes?

Are you (and/or your partner) the primary tenant(s)?

Does the primary tenant pay rent at the market rate?

Do NOT include rent from boarders or lodgers.

That is, your (and/or your partner’s) name is on the tenancy agreement (lease) with the public housing authority.

Go to next question

Go to next question

No

No

Yes You will need to complete and attach a Business details form (Mod F) and a Real estate details form (Mod R). If you do not have these forms, go to www.


88

91

Do you pay site, ground or mooring fees for the home you own (this could be for a caravan, transportable home or boat)?

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?

Go to 107

Go to 107

Go to 107

Go to 97

Go to 98

No

No

Yes

Yes

Yes

Go to next question


Go to 98

No

Yes

Inherited the life interest

Have a formal agreement documenting your right to accommodation for life


Go to 107

Go to 107

Go to 97

92 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?

Go to next question

Go to 94

No

Yes

94

96

95 Details of the payment/transfer

AND/ORWhat assets were transferred?

Market value of assets transferred?

How much did you (and/or your partner) pay?

What date did you (and/or your partner) make this payment/transfer?

Details of the person or organisation the payment/transfer was made to

Full name (of the person or organisation)

Address

/ /

$

$

Postcode

Go to next question

Have an informal arrangement with children to live at their home and pay rent

Informal arrangement, no rent paid

Go to 97

Go to 107

97 What type of accommodation do you (and your partner) live in?

Private house or townhouse/unit/flatCommunity housing

Defence housingCaravan/cabin/mobile home

BoatBoarding house/hostel/private hotel

OtherGo to 99Give details below

Go to next question

SC277.1809 17 of 34

99

100

Do you (and/or your partner) pay board and/or lodgings?

Can you separate the amounts you (and/or your partner) pay for board and/or lodgings?

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).

Go to 101

Go to next question

No

Yes

When did they move in?

/ /

1 Person’s name Age

Do they own the home?

Relationship to you

Their share of the rent/lodgings

No Yes$ per


/ /



Relationship to you


No Yes$ per


/ /



Relationship to you


No Yes$ per


/ /



Relationship to you


No Yes$ per

98 Do you (and your partner) share your accommodation with other people?

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 or members of the armed forces).

If you share with more than four people, attach a separate sheet with details.

Go to next question

Give details below

No

Yes

Total board and lodgings charged per day, week, fortnight, four weeks or calendar month

No

Yes

$ per

Amount paid for board (meals) per day, week, fortnight, four weeks or calendar month

Amount paid for lodgings (accommodation only) per day, week, fortnight, four weeks or calendar month

$ per

$ per

Go to 102

101 How much do you (and/or your partner) pay per day, week, fortnight, four weeks or calendar month (e.g. rent, maintenance or site fees)?

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.

$ per

102 When did you (and/or your partner) start paying this amount?

/ /

103 Do you (and your partner) live in a boarding house, hostel, private hotel, hospital or disability housing?

Go to next question

Go to 105

No

Yes

104 What is the total amount of rent charged for the property per day, week, fortnight, four weeks or calendar month?

$ per

SC277.1809 18 of 34

109 Do you (and/or your partner) own, partly own or have a financial interest in any motor vehicles, motor cycles or trailers?

What is your estimate of the current market value of your (and/or your partner’s) household contents and personal effects?

Go to next question

Give details below

If you (and/or your partner) have more than two motor vehicles, motor cycles or trailers, attach a separate sheet with details.

No

Yes

106

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?

In the last 14 days:• have you (and/or your partner) claimed or been paid an

income support 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?


Yes Attach a full copy of your signed lease or tenancy agreement.

Assets, Income and other financial information

Go to next question

Not Sure Go to next question

No

Yes Go to 151


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.

Your share % Partner’s share %

Current market value

$

Amount owed

$

1 Type of asset (e.g. car) Make (e.g. Ford)

Model (e.g. Focus) Year

Current market value Amount owed

$ $


2 Type of asset (e.g. car) Make (e.g. Holden)

Model (e.g. Astra) Year


$ $


105 Details of your landlord, authorised agent or person you (and/or your partner) pay rent to

Full name

Address

Contact phone number

Postcode

( )

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110 Do you (and/or your partner) own, partly own or have a financial interest in any boats or caravans/motor homes?

Go to next question

Give details below

If you (and/or your partner) have more than two boats, caravans or motor homes, attach a separate sheet with details.

No

Yes

Do NOT include a boat or caravan that is your principal home.

111

112

113

Do you (and/or your partner) have an interest in any other real estate in and/or outside Australia?

How many other properties in and/or outside Australia do you (and/or your partner) own or have an interest in?

Give details below of any OTHER accounts held by you (and/or your partner) in banks, building societies or credit unions.

Go to 113

Go to next question

No

Yes

You will need to complete and attach a Real estate details form (Mod R) for each property. If you do not have this form, go to www.


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. statements, passbooks). Copies can be provided.

1Name of bank, building society or credit union

Type of account

Account number (this may not be your

card number)

Balance of account

Currency if not AUD

Your share

$

% %Partner’s share

Branch number (BSB)


Type of account


card number)

Balance of account

Currency if not AUD

Your share

$


Branch number (BSB)

2 Type of asset (e.g. caravan) Make (e.g. Jayco)

Model (e.g. Heritage) Year


$ $


1 Type of asset (e.g. boat) Make (e.g. Quintrex)

Model (e.g. Coastrunner) Year


$ $


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If you (and/or your partner) have more than five accounts, attach a separate sheet with details.

114 Do you (and/or your partner) have a life insurance policy that can be cashed in?

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.

Attach copies of the policy document and the latest statement for each policy.

Go to next question

Give details below

No

Yes

If you (and/or your partner) have more than two insurance policies, attach a separate sheet with details.

Continued


Type of account


card number)

Balance of account

Currency if not AUD

Your share

$


Branch number (BSB)


Type of account


card number)

Balance of account

Currency if not AUD

Your share

$


Branch number (BSB)


Type of account


card number)

Balance of account

Currency if not AUD

Your share

$


Branch number (BSB)

1 Name of insurance company

Policy number Surrender value

Your share Partner’s share% %

$

2 Name of insurance company

Policy number Surrender value


$

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Attach a copy of a document which gives details for each bond or debenture.

115 116Do you (and/or your partner) have any bonds or debentures? Do you (and/or your partner) have any funeral bonds/funeral investments?

Go to next question

Give details below

No

Yes

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.

Including a pre-paid funeral.

If you (and/or your partner) have more than three bonds or debentures, attach a separate sheet with details.

1 Name of company

Current amount invested Currency if not AUD

Type of investment


2 Name of company


Type of investment


3 Name of company


Type of investment


Go to 118

Give details below

No

Yes

1 Name of company

Name of product

Current value as per latest statement Your share Partner’s share

APIR codePurchase price incl. instalments but not interest

$ % %

2 Name of company

Name of product

Current value as per latest statement Your share Partner’s share

APIR codePurchase price incl. instalments but not interest

$ % %

If you (and/or your partner) have more than two funeral bonds/ funeral investments, attach a separate sheet with details.

117 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?

Go to next question

Attach a copy of each contract.

No

Yes

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If you (and/or your partner) have more than three loans, attach a separate sheet with details.

If you (and/or your partner) have more than three share holdings, attach a separate sheet with details.

118 119Do you (and/or your partner) have money on loan to another person or organisation?

Do you (and/or your partner) own any shares, options, rights, 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 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. Include shares traded in exempt stock markets.

Do NOT include:• managed investments• investments purchased with a margin loan.

Attach a copy of a document which gives details for each loan (if available).

Attach the latest statement for each share holding.

Go to next question

Go to next question

Give details below

Give details below

No

No

Yes

Yes

1 Name of company

Country if not Australia Your share Partner’s share

Number of shares or other securities ASX code (if known)

% %

2 Name of company



% %

3 Name of company



% %

1 Who did you lend the money to?

Current balance on loan Lent by youLent by your partner

Date lent Amount lent

$ % %

/ / $




$ % %

/ / $




$ % %

/ / $

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If you (and/or your partner) have more than two share holdings, attach a separate sheet with details.

If you (and/or your partner) have more than two managed investments, attach a separate sheet with details.

120 121Do you (and/or your partner) own any shares, options or rights in PUBLIC companies, NOT listed on a stock exchange?

Do you (and/or your partner) have any managed investments in and/or outside Australia?

Do NOT include:• managed investments• investments purchased with a margin loan

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 identifyindividual financial products.

Attach a copy of a document which gives details (e.g. certificate with number of units or account balance) for each investment.

Attach the latest statement detailing your share holding for each company (if available).

Go to next question

Go to next question

Give details below

Give details below

No

No

Yes

Yes

1 Name of company

Current market value Your share Partner’s share

$ % %

Type of shares Number of shares

2 Name of company

Current market value Your share Partner’s share

$ % %

Type of shares Number of shares

1 Name of company

Name of product (e.g. investment trust)

Number of units


Type of product/option (e.g. balanced, growth)

APIR code (if known)

Currency if not AUD


$

2 Name of company

Name of product (e.g. investment trust)

Number of units


Type of product/option (e.g. balanced, growth)

APIR code (if known)

Currency if not AUD


$

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122

123

Do you (and/or your partner) own any managed investments or securities purchased with a margin loan?

Continued

In the last five 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?

1 Name of margin loan company

Current margin loan balance Your share Partner’s share

Current portfolio APIR code (if known)

$ % %

2 Name of margin loan company

Current margin loan balance Your share Partner’s share

Current portfolio APIR code (if known)

$ % %

Attach a copy of the latest statement detailing your margin loan(s) for each investment.

Go to next question

Go to next question

Give details below

Give details below

No

No

Yes

Yes

If you (and/or your partner) have more than two margin loans, attach a separate sheet with details.

If you (and/or your partner) have given away or sold for less than its market value more than three items, attach a separate sheet with details.

If you (and/or your partner) have more than one margin loan, attach a separate sheet with details.

Include forgiven loans and shares in private companies.

1 What you gave away or sold for less than its market value (e.g. money, car, second home, land, farm)

Date given or sold What it was worth

/ / $

What you got for it Your share Partner’s share

$ % %

Was this gift to a Special Disability Trust (SDT)? No Yes



/ / $


$ % %




/ / $


$ % %


124 In the last 12 months have you (and/or your partner) borrowed an amount which is secured against your home?

Include:• Home Equity Conversion Loan• Reverse Equity Mortgage.Do NOT include:• a mortgage taken out to purchase your home.

Attach a copy of the loan agreement or contract.

Go to next question

Give details below

No

Yes

Name of the organisation agreement entered into with

Address of the organisation

Postcode

Entered into by: You Your partner

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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.

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 at1 July 1952 to 31 December 1953 65 years and 6 months1 January 1954 to 30 June 1955 66 years1 July 1955 to 31 December 1956 66 years and 6 monthsFrom 1 January 1957 67 years

Go to next question

Give details below

Attach a copy of the latest statement for each superannuation investment. If you have a SMSF or SAF, attach the financial returns and member statement for the fund.

If you (and/or your partner) have more than two superannuation investments, attach a separate sheet with details.

If you (and/or your partner) have more than two income stream products, attach a separate sheet with details.

1 Name of institution/fund manager

Name of fund

Date of joining/investment Current market value

Owned by: You Your partner

/ / $

1 Name of product provider/SMSF/SAF

Type of income stream

Product reference number Commencement date


/ /

2 Name of product provider/SMSF/SAF

Type of income stream

Product reference number Commencement date


/ /

2 Name of institution/fund manager

Name of fund

Date of joining/investment Current market value


/ / $

No

Yes


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).

126

Do you (and/or your partner) receive income from any income stream products?

Go to next question

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 www.


No

Yes

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Go to next question

Go to next question

Go to 132

Go to next question

Give details below

Give details below

Give details in the next column

Give details below

If you (and/or your partner) have more than three investments, attach a separate sheet with details.

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.

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.

No

No

No

No

Yes

Yes

Yes

Yes

Do you (and/or your partner) have any money invested in, or do you (and/or your partner) receive income from, any other investments not declared elsewhere on this form?

Do you (and/or your partner) have any other assets (in or outside Australia) that you have not already advised us about on this form?

Do you (and/or your partner) receive payments from an income protection policy?

Do you (and/or your partner) CURRENTLY receive any income from work other than self employment?

127 128

129

130

Attach a copy of a document which gives details for each investment.

Attach a copy of the policy document and the latest statement for this policy.

Attach a copy of payslip(s) for the last eight weeks from each employer.

Name of organisation/company

Currency if not AUD

Current value of investment

Income received in last 12 months

Your share

%

Partner’s share

%

1 Type of investment


Currency if not AUD



Your share

%

Partner’s share

%



Currency if not AUD



Your share

%

Partner’s share

%


Currency if not AUD


Your share

%

Partner’s share

%

1 Description of asset

Currency if not AUD


Your share

%

Partner’s share

%

2 Description of asset

If you (and/or your partner) have more than two other assets, attach a separate sheet with details.

GROSS income from employment includes amounts voluntarily salary sacrificed into superannuation and the value of employer provided fringe benefits.

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If you (and/or your partner) currently get income from more than two jobs, attach a separate sheet with details.

If you (and/or your partner) stopped working for more than two employers, attach a separate sheet with details.

Continued

1 Employer’s name

Australian Business Number (ABN)

Address

Is this work:

Full-time Part-time Seasonal Casual

Personnel, service or clock-card number

GROSS amount earned per fortnight before tax and other deductions

Is this your usual wage?

Who works for this employer?

Phone number

No Yes

You Your partner

$ per fortnight

Hours worked per fortnight per fortnight

( )

Postcode

2 Employer’s name


Address

Is this work:

Full-time Part-time Seasonal Casual

Personnel, service or clock-card number

GROSS amount earned per fortnight before tax and other deductions

Is this your usual wage?

Who works for this employer?

Phone number

No Yes

You Your partner

$ per fortnight

Hours worked per fortnight per fortnight

( )

Postcode


Yes

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)?

131

Fringe benefits – means a benefit received as part of earned income but not as a wage or salary.

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’.

Go to next question

Give details below

No

Yes

In the last 12 months, have you (and/or your partner) stopped working for any employers (including self-employment)?

132

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 www.


1 Employer’s name

Address

Who worked for this employer? You Your partner

Postcode

Phone number

( )

2 Employer’s name

Address

Who worked for this employer? You Your partner

Postcode

Phone number

( )

SC277.1809 28 of 34

Go to next question

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.

No

Yes

In the last 12 months, have you (and/or your partner) received or do you (and/or your partner) expect to receive, any leave entitlement payments from an employer you have worked for?

133

Attach documents which confirm each leave entitlement payment (e.g. letter from employer or Employment Separation Certificate form (SU001)). If you do not have this form, go to www.


Continued

If you (and/or your partner) have more than two entitlements, attach a separate sheet with details.


Yes

Have you (and/or your partner) received a redundancy payment in the last two years?

134

Attach documents which confirm any redundancy payment (e.g. letter from employer or Employment Separation Certificate form (SU001)). If you do not have this form, go to www.


1 Type of leave entitlement payment


Phone number

Job description

( )

Address

Postcode

Number of working days covered by the payment

Date paid or date payable

Employer’s details Name of business

Amount (before tax and other deductions)

Leave entitlement for

$

/ / You Your partner

2 Type of leave entitlement payment


Phone number

Job description

( )

Address

Postcode

Number of working days covered by the payment

Date paid or date payable

Employer’s details Name of business

Amount (before tax and other deductions)

Leave entitlement for

$


SC277.1809 29 of 34

Go to next question

In the last six months have you (and/or your partner) done anyseasonal, contract, or intermittent work?

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.

For example:• a payment from Department of Veterans’ Affairs (DVA), or• New Enterprise Incentive Scheme (NEIS).

No

Yes

Please read this before answering the following question.135

You will need to complete and attach a Seasonal, Contract and Intermittent Work Details form (SU496)). If you do not have this form, go to www.


Go to next question

Go to next question

Date employment ceased

Date employment ceased

Reason you became voluntarily unemployed

No

No

Yes

Yes

In the last 12 weeks have you become voluntarily unemployed?

In the last 12 weeks have you been dismissed from employment due to misconduct?

136

137

Int

Int

/ /

/ /

Go to next question

Give details below

No

Yes

Do you receive payments from sources other than income support payments from the Australian Government Department of Human Services?

138

Attach a letter or other document(s) that shows the reference number and details for each payment (other than payments made by us).

1 Type of payment

Who pays it?

Reference number (if known) Date commenced (if known)

Paid to: You Your partner

/ /

2 Type of payment

Who pays it?

Reference number (if known) Date commenced (if known)

Paid to: You Your partner

/ /

If you (and/ or your partner) receive more than two payments, attach a separate sheet with details.

SC277.1809 30 of 34

Go to next question

Go to next question

Give details below

Give details below

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.

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 (child or parent).

No

No

Yes

Yes

Do you (and/or your partner) receive payments from an authority or agency outside Australia?

Do you (or your partner) receive money from any boarders or lodgers living with you?

139 140

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.

1 Type of payment

Country which pays it?

Authority or agency which pays it?

Date commenced (if known) Paid to:


2 Type of payment





3 Type of payment





If you (and/or your partner) receive more than three payments from an authority or agency outside Australia, attach a separate sheet with details.

If you (and/or your partner) receive money from more than two people living with you, attach a separate sheet with details.

1 Name of person

Relationship to youNumber of meals you provide each day

Amount paid per fortnight Date started paying

Your share

/ /$

% Partner’s share %

2 Name of person

Relationship to youNumber of meals you provide each day

Amount paid per fortnight Date started paying

Your share

/ /$

% Partner’s share %

Go to 146

Go to next question

Are you or have you (and/or your partner) been involved in a private trust in any of the ways detailed above?

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.

No

Yes

Please read this before answering the following question.141

SC277.1809 31 of 34

Go to next question

Go to next question

Go to 146

Go to next questionGo to next question

Go to next question

Go to 146

No

No

No

No

NoYes

Yes

Yes

Yes

Yes

Is the private trust now vested?

Is the private company now deregistered with the Australian Securities and Investments Commission (ASIC)?

Have you (and/or your partner) made any type of gift involving a private trust (either active or vested) in the last five years?

Have you told us about this private trust before?

Have you (and/or your partner) made any type of gift involving a private company (either registered or deregistered) in the last five years?

142

147

143

144

148

You will need to provide evidence of the vesting.

Go to next question

You will need to provide evidence of deregistration.

Go to next question

145

149

Is the private trust a Special Disability Trust (SDT)?

Have you told us about this private company before?

You will need to complete and attach a Private Trust form (Mod PT).If you do not have this form, go to www.


You will need to complete and attach a Private Company form (Mod PC).If you do not have this form, go to www.


Go to next question

You will need to complete and attach a Special Disability Trust form (Mod SDT). If you do not have this form, go to www.


No

No

Yes

Yes

Go to 150

Go to next question

Are you or have you (and/or your partner) been involved with a private company in any of the ways detailed above?

You may be, or have been in the last five 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.

Include:• farming• self-employed• sole trader• partnership• sub-contractor.

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

Yes


Are you (and/or your partner) involved in any type of business?

Please read this before answering the following questions.

146

150

151

Go to next question

Go to next question

No

No

Yes

Yes

You will need to complete and attach a 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 www.


You will need to complete and attach a Compensation and damages form (Mod C). If you do not have this form,go to www.


Have you (or your partner) ever CLAIMED or are you (or your partner) ABLE TO CLAIM compensation, insurance and/or damages?

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Yes

Are you (and/or your partner) RECEIVING or have you (and/or your partner) EVER BEEN PAID compensation, insurance and/or damages?

152

You will need to complete and attach a Compensation and damages form (Mod C). If you do not have this form, go to www.


Go to next question

Go to next question

Go to next question

Give details below

Give details below

Do NOT include:• compensation, insurance or damages lump sum

payments• funding from the National Disability Insurance Scheme.

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• regular gifts received from an immediate family member

(a parent, child, brother or sister).

No

No

No

Yes

Yes

Yes

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 you (and/or your partner) receive any payments from other sources that you have not already advised us about on this form?

153

154

155

You will need to complete and attach a Claim for Mobility Allowance form (MA001). If you do not have this form, go to www.

humanservices.gov.au/mobilityallowance or call us on 136 150.

Attach the most recent statement/certificate that gives details for each type of payment.

1 Type of payment

Who pays it?

Amount per fortnight Your share Partner’s share

$ % %

2 Type of payment

Who pays it?


$ % %

3 Type of payment

Who pays it?


$ % %

If you (and/or your partner) receive more than three types of payments, attach a separate sheet with details.

1 Type of lump sum

Who paid it?

Amount paid Date paid

Who received this lump sum payment?

/ /$

If you (and/or your partner) have received more than one lump sum payment, attach a separate sheet with details.

You Your partner

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?

You may qualify for an additional payment of Mobility Allowance.

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Yes

Are you a single principal carer who is currently undertaking full-time or part-time study?

156

You will need to complete and attach a Claim for Pensioner Education Supplement (PES) form (SY004). If you do not have this form, go to www.

humanservices.gov.au/pensionereducation or call us on 136 150.

You may qualify for an additional payment of Pensioner Education Supplement.

Checklist

157 Which of the following forms and documents 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.

Where you are asked to supply documents, please attach original documents. In some circumstances copies may be accepted as detailed in the below checklist.

Continued

Identity documents for you (and your partner) (For a list of acceptable documents refer to

Confirming your identity in the Information Booklet)

Authorising a person or organisation to enquire or act on your behalf form (SS313)

(If you answered Yes at question 15)

Copies of documents showing balances for bank, building society and credit union accounts

(Required at question 29)

Relationship details – Separated under one roof form (SS293)

(Completed by you and one completed by your partner if you answered No at question 39)

(Completed by you ONLY if you answered Yes at question 39)

Verification of Relationship Status form (SC321) (If you answered No at question 60)

Dependent children proof of birth (If you answered No at question 77)

Details of additional children (If you answered No at question 78)

Real estate details form (Mod R) (If you answered Yes at question 85 and/or question 86)

Business details form (Mod F) and Real estate details form (Mod R)


Full copy of your signed lease or tenancy agreement(if you answered Yes at question 106)

Real estate details form (Mod R) (If you answered Yes at question 112)

Copies of documents showing balances for bank, building society and credit union accounts

(Required at question 113)

Copies of insurance policy documents and latest statements


Copies of investment bond/debenture documents (If you answered Yes at question 115)

A copy of funeral bond contract(s) (If you answered Yes at question 117)

Copies of money on loan documents (if available)(If you answered Yes at question 118)

Copy of the latest statement for each shareholding LISTED on a stock exchange


Copy of the latest statement for each shareholding NOT listed on a stock exchange


Copies of managed investment certificates or similar documents


Copies of the latest statement for margin loans for each investment


Copy of the loan agreement or contract(If you answered Yes at question 124)

Copies of the 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(If you answered Yes at question 125)

Latest schedules for income stream products OR Details of income stream product form (SA330)


Copies of documents with details of investments(If you answered Yes at question 127)

Copies of income protection policy documents and latest statements


Copies of payslip(s) for the last eight weeks from each employer


Copy of Fringe Benefit details(If you answered Yes at question 131)

Documents which confirm you stopped work OR Employment Separation Certificate form (SU001)


Documents which confirm leave entitlement payment OR Employment Separation Certificate form (SU001)


Documents which confirm redundancy payment OR Employment Separation Certificate form (SU001)


Seasonal, Contract & Intermittent Work Details form (SU496)


Copies of letters/documents with details of other Australian government payments


Copies of documents with details of payments by authorities or agencies outside Australia


Copy of evidence of the vesting of the private trust(If you answered Yes at question 142)

SC277.1809 34 of 34

Continued

158 You (and your partner) need to read this

Privacy and your personal informationYour 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 where you have agreed to that, or where it is required or authorised by law (including for the purpose of research or conducting investigations).You can get more information about the way in which the department will manage your personal information, including our privacy policy, at www.humanservices.gov.au/privacy

159 Declaration

I declare that:• the information I have provided in this claim is complete

and correct.I understand that:• I must return all supporting documents at the same time as

I lodge my claim form. If I do not return all documents, my claim may not be accepted. The only exception will be if I am waiting for medical evidence or other documents from a third party.

• 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 a Job Plan and will take all reasonable steps to meet the terms of this Plan.

• a Job Plan means an Employment Pathway Plan under the Social Security Act 1991.

• Mutual Obligation Requirements means Activity Test or participation requirements under the Social Security Act 1991.

• 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

Partner’s signature

Date

Date

/ /

/ /

Privacy notice

This declaration must be read and signed by you (and your partner).

/ /

OFFICE USE ONLY

CRN

Date of receipt

Private Trust form (Mod PT)(If you answered No at question 145)

Special Disability Trust form (Mod SDT)(If you answered Yes at question 145)

A copy of evidence of the deregistration of the private company


Private Company form (Mod PC)(If you answered Yes at question 149)

Business details form (Mod F) and Real estate details form (Mod R)


Compensation and damages form (Mod C)(If you answered Yes at question 151 and/or question 152)

Claim for Mobility Allowance form (MA001)(If you answered Yes at question 153)

Copies of documents with details of other payments(If you answered Yes at question 155)

Claim for Pensioner Education Supplement (PES) form (SY004)


You can return this form and any supporting documents:• online (excluding identity documents) using your Centrelink

online account. For more information, go to www.

humanservices.gov.au/submitdocumentsonline• by post to:

Department of Human ServicesFamiliesPO Box 7802CANBERRA BC ACT 2610

• in person at one of our service centres, if you are unable to use your Centrelink online account.

Returning your form