claim for service pension part a Ð eligibility · claim for service pension part a Ð eligibility...

Claim for Service PensionPart A – Eligibility

D503 10/09 P1 of 16

Informal claim received

This claim needs to be returned by

Claim issued by Officer

Comments – Issuing Office

Please tick the appropriate boxes.Please use black or blue pen.If you are asked to provide copies of documents, you must providecertified copies (see ‘Who can certify copies of documents’ in thebooklet About Claiming Service Pension), or original documents canbe sighted and verified by a DVA officer.

This form asks about • your personal details, your partner and dependants

• your residence in Australia

• your living arrangements

• your bank account and tax details.

With this form you should have received the booklet AboutClaiming Service Pension. Included in the booklet is informationabout DVA’s reason for collecting the information, and the persons,agencies and bodies to whom the information is usually disclosed.If you don’t have this booklet, contact your nearest DVA or VAN office.

This is Part A of a two part claim form. To avoid delays in processingyour claim, please ensure both Part A and Part B are lodged together.

Information about proof of identity is in the booklet About ClaimingService Pension. You should contact DVA if you are still unsure aboutwhether you need to provide documents.

OFFICE USE — to be completed when forms are issued

Completing this form

If you have a partner On this form: the term ‘you’ refers to the Veteran; the term ‘partner’refers to the current partner of the Veteran. You will need to give detailsof your partner, even if your partner is not applying for service pension.

Booklet

Two part claim

Veteran

Partner

Family name Date of birth File number (if known)Given name(s)

Are dependent children included in this claim? No Yes

Proof of identity

About your claimSECTION A

Veteran detailsSECTION B

D503 10/09 P2 of 16

1 Are you applying for ageservice pension?

3 Are you a registered memberof the Pension BonusScheme?

No Go to question 4Yes You MUST claim the Pension Bonus when you apply for service pension.

4 Do you wish to REGISTER andCLAIM for the Pension BonusScheme?

NoYes If you wish to claim service pension immediately, you need to complete and lodge

BOTH the Registration for Pension Bonus Scheme form (D641) AND theClaim for Pension Bonus form (D559) at the same time as lodging this claimfor service pension. Please include a statement that outlines the specialcircumstances why you did not previously register for the scheme. If you lodge thisclaim for service pension and you receive service pension before lodging the othertwo forms, you cannot ever receive the Pension Bonus.

Complete and attach the Claim for Pension Bonus form (D559).

Go to question 5

Pension Bonus File Number

Where did you register? DVA Centrelink Both

Give details of your registration:

When did you register?

Go to question 5

Complete and attach the Registration for Pension BonusScheme form (D641) and the Claim for Pension Bonus form(D559).

No Go to question 2Yes

5 Your full name

Family name

Given name(s)

Title Mrs Miss Ms OtherMr

Please attach a certified copy of yourfull birth certificate

Go to question 3

Attach completed Invalidity Details form(D569)

Attach a report from an ophthalmologist givingdetails of the degree of visual impairment.

Blind

Neither

2 On what grounds are youapplying for invalidity servicepension?

TPI (Only tick this box if you receive a TPI pension)

The next question must be answered because once you receive service pension, you cannot ever receive the Pension Bonus. For more information, contact your nearest DVA or VAN office.

Go to question 3 if you are a male veteran over 60 years but under 65 OR a female veteranover 58 years but under 63. You must answer question 3 about the Pension Bonus Scheme.Otherwise go to question 5.

From 20 September 2009the Pension Bonus Schemeclosed to new entrants.If you turned pension agebefore 20 September youmay still be able to register.Please refer to FactsheetIS07 Pension BonusScheme for details.

SECTION B continuedVETERAN DETAILS

D503 10/09 P3 of 16

7 Have you ever used or beenknown by other names?e.g. name at birth, maidenname, previous married name.

10 Date of birth

Yes

No

8 Sex Male Female

List the other names

11 Home address(the address where you live)

POSTCODE

POSTCODE

Type of name (e.g. maiden name)

12 Postal address(if same as home address,write ‘ AS ABOVE’)

13 Your contact details Home telephone number ( )

Please provide certified copies of documentary evidence of your namechange (e.g. deed poll, government issued marriage certificate)

Service number

Country of enlistment

Country of forces served in

6 What are your servicedetails?

9 Have you previously providedDVA with proof of youridentity?A list of acceptable documentsis in the information booklet About Claiming Service Pension in the section ‘Provingyour identity to DVA’

Yes

No

Please attach 1 certified copy of a document from Category B thatproves your identity.

Please attach at least 3 certified copies of documents that prove youridentity.

Mobile telephone number

Fax number ( )

Work telephone number ( )

Alternative telephone number ( )

SECTION B continuedVETERAN DETAILS

D503 10/09 P4 of 16

19 What is your CURRENTmarital status?

OR

Single

Date of divorceDivorced

Date of partner’s death

Widowed Name of deceased partner

Have a partner, butunable to live togetherbecause of ill health orinfirmity

Period unable tolive together: from to

Married and currentlyliving together

Living in a marriage-likerelationship

Separated Date of separation

Date of marriage

Date commenced livingtogether

What is the Customer ReferenceNumber (CRN) on the card?

16 Do you currently hold aCommonwealth SeniorsHealth Card (CSHC) fromCentrelink?

Yes

No

Amount you receiveper fortnight

17 Are you receiving (orapplying for) a paymentfrom Centrelink?This includes for example,age pension, disabilitysupport pension, ABSTUDYand payment under the NewEnterprise Incentive Scheme(NEIS).

Yes

No

Type of payment

$

Customer ReferenceNumber (CRN)Date ofapplication/grant

Go to question 35

Go to question 35

Go to question 35

Go to question 35

14 Do you receive a DVAdisability pension? YesNo

Regional Office

Attach a certified copy ofthe marriage certificate.

Complete and attach aSeparation fromPartner form (D513).

18 Are you receiving DefenceForce Income SupportAllowance (DFISA)? Yes

No

indefinite

Type of payment

15 Do you receive or are youclaiming compensation underthe Military Rehabilitation andCompensation Act 2004(MRCA)?

Yes

No

Partner detailsSECTION C

D503 10/09 P5 of 16

26 Is your partner receivingservice pension, incomesupport supplement ordisability pension from DVA?

20 Your partner’s full name

21 Has your partner everused or been known byother names?e.g. name at birth, maidenname, previous married name.

23 Partner’s date of birth

YesNo

22 Partner’s sex Male Female

List the other names Type of name (e.g. maiden name)

25 If the partner lives at adifferent address to theveteran:Partner’s home address,postal address and homephone number

POSTCODE

Family name

Given name(s)

Title Mrs Miss Ms OtherMr

Amount received perfortnight

28 Is your partner receiving(or applying for) a paymentfrom Centrelink?This includes for example,age pension, disabilitysupport pension, ABSTUDYand payment under the NewEnterprise Incentive Scheme(NEIS).

Yes

No

Type of payment

$

Customer ReferenceNumber (CRN)Date ofapplication/grant

Yes

No

Regional Office

Home phone ( )

Home address

POSTCODE

Postal address

Type of payment

Is the phone account in your (and/or your partner’s) name? YesNo

27 Is your partner receiving orclaiming compensation underthe Military Rehabilitation andCompensation Act 2004(MRCA)?

Yes

No

Type of payment

24 Has your partner previouslyprovided DVA with proof oftheir identity?A list of acceptable documentsis in the information booklet About Claiming Service Pension in the section ‘Provingyour identity to DVA’

Yes

No Please attach at least 3 certified copies of documents that prove yourpartner’s identity.

Please attach 1 certified copy of a document from Category B thatproves your partner’s identity.

Please provide certified copies of documentary evidence of your namechange (e.g. deed poll, government issued marriage certificate.

SECTION C continuedPARTNER DETAILS

D503 10/09 P6 of 16

33 Does your partner wish toregister for the Pension BonusScheme?

32 Is your partner a registeredmember of the PensionBonus Scheme?

No

Yes Your partner MUST claim the Pension Bonus when they apply for service pension.

Please attach a certified copy of your partner’s full birth certificate.

Complete and attach the Claim for Pension Bonus form (D559).

Pension Bonus File Number

Where did your partner register? DVA Centrelink Both

Give details of your partner’s registration:

When did your partner register?

Your partner needs to complete and lodge the Registration for PensionBonus Scheme form (D641).

Go to question 33

If your partner wishes to claim partner service pension immediately,BOTH the Registration for Pension Bonus Scheme form (D641)AND the Claim for Pension Bonus form (D559) should becompleted and lodged at the same time as this claim for servicepension. Please include a statement that outlines the specialcircumstances why your partner did not previously register for thescheme. If your partner lodges this claim for service pension andreceives service pension before lodging the other two forms, yourpartner cannot ever receive the Pension Bonus.

31 Does your partner wish toapply for partner servicepension? (Refer to page 3 ofthe About Claiming ServicePension booklet for moreinformation).

No

Yes

You must continue to give details when this form asks about ‘your partner’.

Go to question 35

Complete and attach the Registration forPension Bonus Scheme form (D641) and theClaim for Pension Bonus form (D559).

Neither Partner is not yet pension age.

If you are unsure aboutwhether your partner shouldbe applying, contact DVA todiscuss.

30 Is your partner receivingDefence Force IncomeSupport Allowance (DFISA)?

No

Yes

No Go to question 34

Yes

34 Does your partner wish toregister for and claim thePension Bonus?

Neither Partner is not yet pension age.

No Go to question 35Yes

What is the referencenumber on the card?

29 Does your partner currentlyhold a CommonwealthSeniors Health Card(CSHC) from Centrelink?

Yes

No

Dependent childrenSECTION D

D503 10/09 P7 of 16

Yes

No

Give details

35 Do you (and/or your partner)have any dependent childrenunder 16 years of age?This means that you are legallyresponsible for the day-to-daycare, welfare and developmentof a child who is in your care orwholly or substantially in yourcare.

Child’s full name

Date of birth

Is the child at school? $Gross fortnightly income

Yes

No

Give details

36 Do you (and/or your partner)have any dependent childrenaged 16-22 years of age whoare in full-time education?

NoYes

1

Child’s full name

Date of birth

Does the child receiveany governmentpayments?

Type of paymentNo Yes

1

$Other gross fortnightly income

2

3

2

3

Child’s full name

Date of birth

Is the child at school? $Gross fortnightly incomeNoYes

Child’s full name

Date of birth

Is the child at school? $Gross fortnightly incomeNoYes

Child’s full name

Date of birth



Child’s full name

Date of birth



Please attach a certified copy of the birth certificate/extract for each child.

Please attach a certified copy of the birth certificate/extract for each child.

Go to question 36

Go to question 37

FemaleMale

FemaleMale

FemaleMale

FemaleMale


FemaleMale


FemaleMale

Amount of payment $

Amount of payment $

Amount of payment $

Residence in AustraliaSECTION E

D503 10/09 P8 of 16

39

40

VETERAN PARTNER who is applying

YesNo YesNo

41 Were you born in Australia? Was your partner born in Australia?

The holder of a special purpose visa

Are you: An Australian citizenThe holder of a permanent visa

Is your partner:

Are you living permanentlyin Australia?

Is your partner livingpermanently in Australia?

If you are the holder of a permanent visa, special purpose visa or special categoryvisa, attach a copy of documents that show that you (and your partner) are legallyallowed to remain in Australia — for example, passport showing your visa.

The holder of a special purpose visa

An Australian citizenThe holder of a permanent visa

43 Have you moved to orreturned to live in Australiain the last 12 months?

Has you partner moved to orreturned to live in Australia inthe last 12 months?

37 Did you serve in the Australian Defence Force?

Please attach a copy of documents thatshow you have had at least 10 yearscontinuous residence in Australia. If youhave broken periods of residence thatadd up to more than ten years and oneof the broken periods was at least fiveyears, you may satisfy the residencerequirements. Please attach a copy ofdocuments showing this.

42 Have you ever lived overseas? Has your partner ever lived overseas?

No

Yes

The holder of a special category visa The holder of a special category visa

Go to question 38Go to question 39

38 Did you serve in British, Commonwealth or allied forces?

No

Yes

A refugee or a former refugee

YesNo YesNo

Yes Go to question 43Yes Go to question 43

Yes Go to question 42 Yes Go to question 42

When did you first arrive in Australia?

No

How long have you lived in Australia?

years monthsGo to question 43

Country of birth

When did your partner first arrive in Australia?

How long has your partner lived in Australia?

years months

No

Go to question 43

Country of birth

No Go to question 44No If applicable, go to the ‘PARTNER who is applying’column. Otherwise, go to question 44

Living arrangementsSECTION F

D503 10/09 P9 of 16

44 Do you have a partner whois applying and who lives ata different address becauseof age or ill health?

Yes

No

Type of accommodation (from the list below)

If required, give details at the relevant question in this section.(If they live in the same type of accommodation but a differentaddress, you may need to give the details on an attachment.)

45 Which of the following bestdescribes where you live?

In a home you (and/or your partner) ownThis includes paying it off (mortgage).

In a retirement village or independent living unit

Go to question 53on page 12

Go to question 46on the next page

In accommodation which you have the rightto use free for lifeSuch as a granny flat.


In private rental accommodation, caravan parkor moored craft


Other—please describeGo to question 53on page 12

In a home you (and/or your partner) own jointlywith another person or organisation


In a home owned by a private trust Go to question 53on page 12

In a home owned by a private company Go to question 53on page 12

In a place where you pay private board and lodging Go to question 51on page 11

In free accommodationSuch as living with relatives


In public housingSuch as government subsidised, Housing Trustetc.


In a relocatable homeSuch as a home situated in a village orcaravan park where you are paying site fees


Go to the next question

This question must beanswered in ALL cases.

In a residential aged care home (nursing home orhostel) which provides nursing care


In a hospital or home for peoplewith disabilities


SECTION F continuedLIVING ARRANGEMENTS

D503 10/09 P10 of 16

46 Give details about youraccommodation in theretirement village

Amount

Date you started paying

per

YesNo How much?Did you pay an entrycontribution?

How much do you pay on-goingfor your accommodation?

Go to question 53

On what date did you move into this accommodation?

49 Did you pay a sum ofmoney or transfer anyassets to another personor organisation in returnfor this accommodationfor life?

Yes

No

Market value ofassets transferred

What assets weretransferred

Date paid/transferred

$Amount paid

OR

$

Go to question 53

Go to question 53

Retirement village or independent living unit

Life interest

Name and addressof person ororganisation

$

$

Does this include acomponent for meals? YesNo

Please attach a certified copy of the entry agreement.

POSTCODE

47 Give details about youraccommodation in thenursing home or hostel

Amount

Date you started paying

per$

YesNoDid/do you pay anaccommodationbond or charge?

How much do you pay on-goingfor your accommodation?

Go to question 53

Residential aged care home (nursing home or hostel) which provides nursing care

What is the name of thenursing home or hostel?

Please attach a certified copy of theAccommodation Bond or theAccommodation Charge Agreement.Ensure bond or charge amount isshown.

48 Give details about youraccommodation in thehospital or home

Go to question 53


Please attach a certified copy of the accommodationagreement or other relevant documentation.

Hospital or home for people with disabilities

SECTION F continuedLIVING ARRANGEMENTS

D503 10/09 P11 of 16

Go to question 5350 Give details Type of payment:

52 Give details of the providerof the free accommodation

Go to question 53

Please attach a certified copy of your latest lease or tenancy agreement.If you don’t have one, then attach a certified copy of the latest rent receipt.Make sure the name and address of the person to whom you pay rent is writtenon the receipt.

51 Give details of yourboard and lodging

Amount paid for meals

Amount paid for lodging $

per$

per

Private rent, public housing, caravan park, moored craft

Private board and lodging

Free accommodation

Name

Relationship to you

Address

Please attach a copy of your latest lease or tenancy agreement.If you don’t have one, then attach a certified copy of the latest receipt.Make sure the name and address of the person to whom you pay board andlodging is written on the receipt copy or on an attachment.

Go to question 53

Go to question 53

Public housing

Private rent

Caravan park site fees

Mooring fees

How much do you pay?

Who do you pay it to?(name and contactdetails)

per$


Who do you pay it to?(name and contactdetails)

POSTCODE

Relocatable home park site fees

Public housing renters are noteligible for rent assistance.

Blind or visually impairedSECTION G

RepresentativeSECTION H

D503 10/09 P12 of 16

54 Are YOU applying as a personwho is blind or visuallyimpaired (ie regarded aspermanently blind in botheyes)?

YesNo

If you are eligible for Rent Assistance, do you wish to receive it?

The income and assets tests apply —complete Part B – Income and Assets.

Please complete and attach a Compensation form (D541)for each injury, illness or accident.

57 Do you want a representativeto act on your behalf?

The income and assets tests do not apply to you and you do not have tocomplete Part!B – Income and Assets, except as follows:

If you have a partner who is applying and is NOT blind or visually impaired, theincome and assets tests apply — complete Part B – Income and Assets.

Yes

No

If you (or your partner who is applying) are in an aged care facility, completePart B – Income and Assets. This is needed to assess your aged care fees.

Please attach a certified copy of a letter or other documentwhich shows the reference number and details of the payment.

Go to question 57

Yes

No

Attach a report from an ophthalmologist givingdetails of the degree of visual impairment.

53 Is your PARTNER applying forpartner service pension as aperson who is blind or visuallyimpaired (ie regarded aspermanently blind in both eyes)?

Their name

Address

If someone has Power of Attorney over your affairs, pleaseattach a certified copy of the relevant documentation.If a trustee is to be appointed, the Application forappointment of trustee form (D2505) must becompleted and attached.If you wish to appoint an agent, please complete and attachthe Application for appointment of agent form(D2693).If you do not have a form you require, contact DVA.

For this claimonly

For all futuredealings withDVA

( )Phone number(office hours)

If you want a representative to act on your behalf for thisclaim only, give their contact details

Give detailsYes

No Go to question 58

55 Are you (or your partner)receiving or claimingcompensation?

Yes

No

56 Are you (or your partner)receiving payments underthe New Enterprise IncentiveScheme (NEIS)?

Yes

No

POSTCODE

Attach a report from an ophthalmologist giving details of the degreeof visual impairment if this was not asked for in question 4.

Only answer this question if your partner is applying for partner service pension

Tax detailsSECTION I

D503 10/09 P13 of 16

58 What is your Tax File Number?

Fill in ONE of A or B

My Tax File Number isA

B I do not have or do not know my Tax File Number(DVA can help you get your Tax File Number from theAustralian Taxation Office — you must complete a Tax

file number application or enquiry form NAT 1432)

Your Tax File Number

Partner’s Tax File Number

Once we have recorded your Tax FileNumber, this portion of the page willbe removed and destroyed toensure that your Tax File Numberremains confidential.

Fill in ONE of A or B

My partner’s Tax File Number isA

B My partner does not have or does not know their TaxFile Number (DVA can help them get their Tax File

Number from the Australian Taxation Office— your partner must complete a Tax file number

application or enquiry form NAT 1432)

Tax File NumbersTo help ensure that pensions are only paid to eligible persons, we compare ourrecords with those of other government agencies. Your Tax File Number is used forthis purpose.All matching programs are monitored by the Privacy Commissioner who ensuresthat they are conducted in accordance with the Data-matching Program(Assistance and Tax) Act 1990 and Guidelines.Access to your Tax File Number is restricted. If you lose or forget your number, youwill need to contact the Australian Taxation Office (ATO).For more information about tax and your pension, contact your nearest ATO or DVA.

PARTNER

VETERAN

We need your partner’s Tax File Number,even if your partner is not applying.

PLEA

SE D

O NO

T DE

TACH

Payment detailsSECTION J

D503 10/09 P14 of 16

59 Give details of the account you want your payment made to(If you are already receiving DVA disability pension, do not complete thisquestion.)Payments must be made to a bank, building society or credit union account heldin your name. A joint account is acceptable.

Name of bank, building society or credit union

Branch where your account is held

Account number (this is not always the number printed on your card)

Account held in the name(s) of

Type of account (e.g. savings, cheque)

VETERAN

PARTNER who is applying

60 Give details of the account your partner wants their payment made toPayments must be made to a bank, building society or credit union account heldin your name. A joint account is acceptable.

To the same joint account the Veteran’s payment is made to

OR give details of a different account

Name of bank, building society or credit union

Branch where your partner’s account is held

Account number (this is not always the number printed on your card)

Account held in the name(s) of

Type of account (e.g. savings, cheque)

Branch number (BSB)

Branch number (BSB)

SECTION K

D503 10/09 P15 of 16

Attachment checklist

You must attach documents as evidence of your answers to some of the questions.You must provide certified copies (see ‘Who can certify copies of documents’ in thebooklet About Claiming Service Pension), or original documents can be sighted andverified by a DVA officer.If any of your documents are in a language other than English, you must also providetranslations into English by an accredited translator.You may have already selected some of these documents for your proof of identity.If you do not have a form that you need, contact your nearest DVA or VAN office.Use this checklist to make sure you have attached all the relevant documents.

Continued on the next page

38

Documentary evidence for proof of identity9

46

39

48

A copy of the entry agreement

If you are the holder of a permanent visa, special purpose visa or special category visa,a copy of documents that show that you are legally allowed to remain in Australia

A copy of the Accommodation Bond/Charge Agreement

If your partner is also applying, a copy of your partner’s birth certificate31

1 A copy of your full birth certificate

If you are a British, Commonwealth or allied Veteran, a copy of documents that show youhave had at least 10 years residence in Australia

If claiming Pension Bonus— the Claim for Pension Bonus form (D559)2

Documentary evidence of name change7

If you are married and currently living together a copy of the marriage certificate19

If your partner is claiming payment of the Pension Bonus the Claim for PensionBonus form (D559)

32

A copy of the birth certificate/extract for each dependent child35

47 A copy of the accommodation agreement or other relevant documentation

A copy of the birth certificate/extract for each dependent child36

If registering for and claiming the Pension Bonus the Claim for Pension Bonus form(D559) and the Registration for Pension Bonus Scheme form (D641)

3

If registering for and claiming the Pension Bonus the Claim for Pension Bonus form(D559) and the Registration for Pension Bonus Scheme form (D641)

34

If you are separated the Separation from Partner form (D513)19

Question

Documentary evidence for proof of identity for partner24

4 If applying on the basis of Invalidity (Blind), a report from an opthalamologist givingdetails of the degree of visual impairment. If applying on the basis of Invalidity (Other),Invalidity Details form (D569)

Documentary evidence of name change21

SECTION M

StatementSECTION L

SECTION K continuedATTACHMENT CHECKLIST

D503 10/09 P16 of 16

53

If you would like to specify a person to act on your behalf when dealing with DVA in thefuture documentation appointing a Power of Attorney, the Application forappointment of trustee form (D2505), or the Application for appointmentof agent form (D2693)

What to do now

If you are applying as aperson who is blind or visuallyimpaired

You must complete and attach Part B – Income and Assets (Form D648).

If you and your partner are both applying, you need only complete one Part B – Income andAssets.

If you and your partner choose to provide income and assets details separately, you will needtwo copies of Part B – Income and Assets.

If you need copies of Part B – Income and Assets, contact your nearest DVA or VAN office.

Check question 54 on page 12 to see if you need to complete Part B – Income andAssets.

Before you sign this statement, you should read the information about privacy in thebooklet About Claiming Service Pension in the section ‘About the information you give’.

StatementThis statement must besigned by you and yourpartner (if you have apartner who is applying).If your partner is applying,question 31 must beticked “Yes”. Date

✍

Date

VETERAN’S SIGNATURE

PARTNER’S SIGNATURE – if partner is applying

I declare that the information I have given is correct.I understand that there are penalties for deliberately giving false or misleading information.I authorise Australian Government Departments or agencies (including Centrelink and theAustralian Tax Office) and other organisations to disclose to the Department of Veterans’Affairs any information required to process my claim for service pension.

If receiving or claiming compensation, attach a Compensation form (D541) for eachinjury, illness or accident

57

50 A copy of your latest lease or tenancy agreement or the latest receipt

55

If your partner is applying and is blind or visually impaired, a report from anophthalmologist giving details of the degree of visual impairment

If receiving NEIS, a copy of a letter or other document showing details56

Attach a report from an ophthalmologist giving details of the degree of visualimpairment if this was not asked for in Question 4.

54

Question

51 A copy of your latest lease or tenancy agreement or the latest receipt

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