Claim for Widow Allowance - Australian Government ...€¢ online – submit your documents online (including identity documents). For more information about how to access an Online

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Claim forWidow Allowance

When to use this form Use this form to claim Widow Allowance if you are a female who:

• was born on or before 1 July 1955, and• was widowed, divorced or separated after turning 40 years, and• has no recent workforce experience, and• is an Australian resident.

Recent workforce experience means paid employment of 20 hours or more a week for a total of 13 weeks or more at any time during the last 12 months.

What else you may need to provide

You may need to provide identity documents. For a list of acceptable documents, refer to Confirming your identity in the Information Booklet.

Online Services You can access your Centrelink online account through myGov. myGov is a simple and secure way to access a range of government services online with one username and password. You can create a myGov account at my.gov.au and link it to your Centrelink online account. To make a claim online, access your Centrelink online account through myGov, then select ‘Online Claims’ from the menu.

Filling in this form • Please use black or blue pen.• Print in BLOCK LETTERS.

• Mark boxes like this with a or .

• 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.

Returning your form Check that all required questions are answered and that the form is signed and dated.

Important Note: 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.

You can return this form and any supporting documents:

• online – submit your documents online (including identity documents). For more information about how to access an Online Account or how to lodge documents online, go to humanservices.gov.au/submitdocumentsonline

• by post – return your documents by sending them to:Department of Human Services Centrelink Reply Paid 7800 CANBERRA BC ACT 2610

• in person – if you are unable to submit this form and any supporting documents online or by post, you can provide them in person to one of our service centres.

http://www.my.gov.au

http://www.humanservices.gov.au/submitdocumentsonline

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For more information Refer to Information you need to know about your claim for Newstart Allowance/Widow Allowance (Ci003) (Information Booklet) at humanservices.gov.au/forms

If you need a translation of any documents for our business, we can arrange this for you free of charge.

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

Note: Call charges 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.

http://www.humanservices.gov.au/forms

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1 Do you need an interpreter when dealing with us?

This includes an interpreter for people who have a hearing or speech impairment.

No Go to 4

Yes Go to next question

2 What is your preferred spoken language?

3 What is your preferred written language?

4 Do you have a dependent child under 8 years of age in your care?

No Go to next question

Yes Parenting Payment may be a more appropriate payment for you. Please call us on 136 150.Do NOT continue with this claim.

5 Have you worked in the last 12 months?

No Go to 7


6 Have you worked for 20 hours or more a week, for at least 13 weeks in the last 12 months?

Attach proof of your employment (e.g. a letter from your employer, with the number of hours worked per week over the last 12 months or payslips that show the number of hours you worked ).

Go to next question

No

Yes You may not be eligible for Widow Allowance. Please call us on 132 850.Do NOT continue with this claim.

7

8 Have you ever used or been known by any other name (e.g. name at birth, maiden name, previous married name, Aboriginal or tribal name, alias, adoptive name, foster name)?


Yes Give details below

1 Other name

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

If you have more than 2 other names, attach a separate sheet with details.

2 Other name

Type of name (e.g. maiden name)

9 Your date of birth

/ /

10 Your permanent address

Postcode

11 Your postal address (if different to above)

PostcodeYour name

Mr Mrs Miss Ms Other

Family name

First given name

Second given name

CLK0SU016 1707

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12 Please read this before answering the following question.

If you provide an email address or mobile phone number, you may receive electronic messages (SMS or email) from us. To read the Terms and Conditions, go to humanservices.gov.au/em or visit one of our service centres.

Your contact details

Home phone number ( )

Is this a silent number? No Yes

Whose name is the phone account in? My name

Another name

Mobile phone number

Is this a silent number? No Yes

Whose name is the mobile phone account in? My name

Another name

Fax number ( )

Work phone number ( )

Alternative phone number ( )

Email

@

13 Please read this before answering the following questions.

Questions 13 and 14 are optional and will not affect your payment. If you do answer, the information will help us to continue to improve services to Aboriginal and Torres Strait Islander Australians and Australian South Sea Islanders.Australian South Sea Islanders are the descendants of Pacific Islander labourers brought from the Western Pacific in the 19th Century.

Are you of Aboriginal or Torres Strait Islander Australian origin?

If you are of both Aboriginal and Torres Strait Islander Australian origin, please tick both ‘Yes’ boxes.

No

Yes – Aboriginal Australian

Yes – Torres Strait Islander Australian

14 Are you of Australian South Sea Islander origin?

No

Yes

Do you want to authorise another person or organisation to make enquiries, get payments and/or act on your behalf?


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 humanservices.gov.au/nominees

15

16 Where do you want your payment made?

The bank, building society or credit union account must be in your name. A joint account is acceptable.Do NOT include an account used exclusively for funding from the National Disability Insurance Scheme.

Name of bank, building society or credit union

Branch where the account is held

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. ATM slip(s), statement(s), passbook(s)).

17 What is your current relationship status?

Separated (includes de facto and registered)

Divorced

Widowed

Go to 19

Go to 19

Go to next question

Please give the following details about your deceased partner

Full name

Date of birth Date of death

/ / / /

Go to 21

18

Attach a copy of the death certificate (if available).

http://www.humanservices.gov.au/em

http://www.humanservices.gov.au/nominees

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19 Do you live in the same home as your former partner?


Yes

20 Please give the following details about your former partner

Full name

Date of birth Date relationship ended

/ / / /

Current address (if known)

Postcode

You will need to complete and attach an Relationship Details Separated Under One Roof form (SS293). If you do not have this form, go to humanservices.gov.au/forms

Go to 21

You will need to provide proof of your Australian residence status (e.g. citizenship papers, passport or other documentation).

Go to next question

21

22 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

23 Are you an Australian citizen who was born in Australia?

No

Yes Go to 35

24 What is your country of birth?

30 When did you most recently start living in Australia?

27 What type of visa did you arrive on?

New Zealand passport (Special Category visa)

Go to 29

Permanent Go to next question

Temporary Go to next question

Unknown (e.g. arrived on parent’s passport)

Go to 29

28 Your visa details on arrival

Visa sub class Date visa granted

/ /

29 Has your visa changed since you arrived in Australia?


Yes Most recent visa details

Visa sub class Date visa granted

/ /

31 Did you start living in Australia before 1965?


Give details belowYes

Name of the ship or airline on which you arrived

Name of the place where you first arrived/disembarked

What was your name when you first arrived in Australia?

/ /

No

Not applicable – Never travelled to Australia

Yes

Go to next question

Go to next question

Give details below

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

25 What is your country of citizenship?

Australia

Other Give details below

Date granted

/ / Go to 35

Country of citizenship

Date granted

/ /

26 Have you ever lived in Australia?

No Go to 36



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33 Did your former partner or either of your parents arrive on a refugee or humanitarian visa?

No

Yes

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

No

Not sure

Yes


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?


Yes 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.

1

2

3

4

5






From

From

From

From

From

/ /

/ /

/ /

/ /

/ /

To

To

To

To

To

/ /

/ /

/ /

/ /

/ /

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

36 Do you own a home but live elsewhere?


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

Travelling away from your home

Being cared for away from your home

Caring for someone away from your home

Living away from home to study


37 Which of the following best describes where you live?

In a home which is owned by a private company or a private trust that you have an interest in Go to 70

In a home you own or you own jointly with another person, this can include:• paying it off (mortgage)• a caravan, transportable home or boat Go to 38

In accommodation which you have the right to use for life Go to 54

In public housing (e.g. housing owned by the Housing Authority. This does not include paying rent to a Community Housing organisation.) Go to 42

In a place where you pay private rent (this includes site or mooring fees) Go to 59

In a boarding house/hostel/private hotel

In a nursing home or aged care hostel

In a retirement village

Go to 62

Go to 45

Go to 51

In accommodation where you pay no rent Go to 70

Other (e.g. this could be where you do not have a fixed address)

Give details below

Go to 59

In a hospital or home for people with disabilities Go to 62

38 Is the home you own on a block of land larger than 2 hectares (5 acres)?


Yes You will need to complete and attach a Real estate details form (Mod R).If you do not have this form, go to humanservices.gov.au/forms

Go to 40

32 Are you a refugee or former refugee?

No

Yes


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39 Does the property that you live on have more than one title document?


Yes You will need to complete and attach a Real estate details form (Mod R).If you do not have this form, go to humanservices.gov.au/forms

Go to 42

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

Do NOT include rent from boarders or lodgers.


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 this form, go to humanservices.gov.au/forms

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

No Do not answer questions 42 to 69.Go to 70

Yes Go to 59

42 Are you the primary tenant?

That is, your name is on the tenancy agreement (lease) with the public housing authority.


Yes Do not answer questions 43 to 69.Go to 70

43 Does the primary tenant pay rent at the market rate?


Not sure Go to next question

Yes Go to 60

44 Do you live with the primary tenant AND your income has been taken into account by the public housing authority when calculating the rent?

No Do not answer questions 45 to 69.Go to 70

Yes Go to 60

45 Name of aged care hostel/nursing home

46 What date did you move into the aged care hostel or enter the nursing home?

/ /

47 How long will you be staying?

Long term or indefinitely

Respite care

Go to next question

When do you expect to leave?

/ /

Do not answer questions 48 to 69.Go to 70

48 Does this aged care hostel or nursing home receive an Australian Government subsidy for your accommodation?

Check with your service provider to find out if they receive any Australian Government subsidy.

No

Not sure Go to next question


Attach copies of documents to verify the details of the entry agreement for daily fees.

Go to next question

49 Did you or are you paying an accommodation payment?

Your accommodation payment may have been a donation, a loan or some type of payment which may be repayable to you in whole or in part, if you leave. An accommodation payment does not include gifts or loans above the amount you had to pay for the right to your accommodation.


How much accommodation payment did you pay?Yes

$

Attach a copy of the accommodation payment agreement.

50 Did you make a gift and/or loan in addition to the accommodation payment?

No Go to 70

How much was the gift?

How much was the loan?

Yes

$

$

Go to 70

51 What date did you move into the retirement village?

/ /



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52 Did you pay an entry contribution?

Your entry contribution may have been a donation, a loan or some type of payment which may be repayable to you in whole or in part, if you leave. An entry contribution does not include gifts or loans above the amount you had to pay for the right to your accommodation.


How much entry contribution did you pay?Yes

$

Attach a copy of the document which verifies the details of your entry contribution (e.g. your contract).

53 Did you make a gift and/or loan in addition to the entry contribution?

No Go to 60

How much was the gift?

How much was the loan?

Yes

$

$

Go to 60

54 Did you pay a sum of money and/or transfer assets to another person in return for this accommodation for life?


Go to 56Yes

55 Tick which option describes how you obtained a life interest in a home without any exchange of money or transfer of assets:

Inherited the life interest

Have a formal agreement documenting your right to accommodation for life

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

Informal arrangement, no rent paid


Go to 70

Go to 70

Go to 59

Go to 70

Go to 59

56 What date did you make this payment/transfer?

/ /

57 Details of the payment/transferHow much did you pay?

$

AND/OR

What assets were transferred?

Market value of assets transferred?

$

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

Full name (of the person or organisation)

Address

Postcode

59 What type of accommodation do you live in?

Private house or townhouse/unit/flat

Community housing

Defence housing

Caravan/cabin/mobile home

Boat

Boarding house/hostel/private hotel

Other

Go to next question

Go to 62

Give details below

Go to next question

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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).

Do you share your accommodation with other people?

No Go to 62


1 Person’s name Age

When did they move in?

/ /

Your relationship to this person

Their share of the rent/lodgings

$ per

Do they own the home?

No Yes



/ /



$ per


No Yes



/ /



$ per


No Yes



/ /



$ per


No Yes

If you share with more than 4 people, attach a separate sheet with details.

61 Do you share your accommodation with one or more of your children who receive a Centrelink payment, ABSTUDY or a service pension but do NOT receive Rent Assistance?

No

Yes

62 Do you pay board and/or lodgings?

Board means you are provided with some regular meals.Lodgings means no meals are provided to you.

No Go to 64


63 Can you separate the amounts you pay for board and/or lodgings?

No

Yes

Total board and lodgings charged per day, week, fortnight, 4 weeks or calendar month

$ per

Amount paid for board (meals) per day, week, fortnight, 4 weeks or calendar month

Amount paid for lodgings (accommodation only) per day, week, fortnight, 4 weeks or calendar month

Go to 65

$ per

$ per

64 How much do you pay per day, week, fortnight, 4 weeks or calendar month (e.g. rent, maintenance or site fees)?

This would be the total you pay for the property minus any subsidy/rebate or contribution from another person or organisation.

$ per

65 When did you start paying this amount?

/ /

66 Do you live in a boarding house, hostel, private hotel, hospital or disability housing?


Yes Go to 68

67 What is the total amount of rent charged for the property per day, week, fortnight, 4 weeks or calendar month?

$ per

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68 Details of your landlord, authorised agent or person you pay rent to

Full name

Address

Postcode

Contact phone number

( )

69 Do you have a current lease or tenancy agreement with written evidence of the CURRENT amount of rent, fees, lodgings or board and lodgings you pay?


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


The current market value of an item is what you would get if you sold it. It is not the replacement or the 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.

What is your estimate of the current market value of your household contents and personal effects?

Current market value

$

Amount owed

$

71 Do you own, partly own or have a financial interest in any motor vehicles, motor cycles or trailers?



1

2

Type of asset (e.g. car)

Type of asset (e.g. car)

Make (e.g. Ford)

Make (e.g. Holden)

Model (e.g. Focus)

Model (e.g. Astra)

Year

Year



$

$

Amount owed

Amount owed

$

$

If you have more than 2 motor vehicles, motor cycles or trailers, attach a separate sheet with details.

Your share

Your share

%

%

72 Do you own, partly own or have a financial interest in any boats or caravans/motor homes?



1

2

Type of asset (e.g. boat)

Type of asset (e.g. caravan)

Make (e.g. Quintrex)

Make (e.g. Jayco)

Model (e.g. Coastrunner)

Model (e.g. Heritage)

Year

Year



$

$

Amount owed

Amount owed

$

$

Your share

Your share

%

%

If you have more than 2 boats, caravans or motor homes, attach a separate sheet with details.

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73 Give details below of any other accounts held by you in banks, building societies or credit unions.

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 funds received from the National Disability Insurance Scheme.

Attach proof of account balances (e.g. ATM slip(s), statement(s), passbook(s)).

1

2

3




Type of account

Type of account

Type of account

Currency if not AUD

Currency if not AUD

Currency if not AUD


card number)


card number)


card number)

Balance of account

Balance of account

Balance of account

$

$

$

Your share

Your share

Your share

%

%

%

If you have more than 3 accounts, attach a separate sheet with details.

74 Do you 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 a copy of the policy document and the latest statement for each policy.

1

2

Name of insurance company

Name of insurance company

Policy number

Policy number

Surrender value

Surrender value

$

$

Your share

Your share

%

%

If you have more than 2 insurance policies, attach a separate sheet with details.

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75 Do you have any bonds or debentures?

Bonds refer to government and semi-government bonds.Include:• investments in and/or outside AustraliaBonds 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.



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

1

2

Name of company

Name of company

Type of investment

Type of investment

Current amount invested


$

$

Currency if not AUD

Currency if not AUD

Your share

Your share

%

%

If you have more than 2 bonds or debentures, attach a separate sheet with details.

76 Do you have any funeral bonds/funeral investments, including a pre-paid funeral?

No Go to 78


1

2

Name of company

Name of company

Name of product

Name of product

Current value as per latest statement

Current value as per latest statement

$

$

Your share

Your share

%

%

APIR code

APIR code

Purchase price incl. instalments but not interest

Purchase price incl. instalments but not interest

If you have more than 2 funeral bonds/funeral investments, attach a separate sheet with details.

77 Do you have 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?


YesAttach a copy of each contract.

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78 Do you have money on loan to another person or organisation?

Include all loans, whether they are made to family members, other people or organisations or trusts.Do NOT include loans to get accommodation in a hostel.



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

1

2

Who did you lend the money to?

Who did you lend the money to?

Current balance of loan

Current balance of loan

$

$

Lent by you

Lent by you

%

%

Date lent

Date lent

Amount lent

Amount lent

/ /

/ /

$

$

If you have more than 2 loans, attach a separate sheet with details.

79 Do you 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 shares traded in exempt stock markets.Do NOT include:• managed investments• investments purchased with a margin loan.

1 Name of company

Country if not Australia Your share

%

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

2 Name of company

Country if not Australia Your share

%

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

If you have more than 2 share holdings, attach a separate sheet with details.

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80 Do you own any shares, options or rights in PUBLIC companies, NOT listed on a stock exchange?

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



Attach a copy of the shares certificate(s) or latest statement detailing your shareholding for each company (if available).

1

2

Name of company

Name of company



$

$

Your share

Your share

%

%

Type of shares

Type of shares

Number of shares

Number of shares

If you have more than 2 share holdings, attach a separate sheet with details.

81 Do you have any managed investments in and/or outside Australia?

Include:• investment trusts• personal investment plans• life insurance bonds• friendly society bonds.Do NOT include:• conventional life insurance policies• investments purchased with a margin loan.APIR code – is commonly used by fund managers to identify individual financial products.



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

1

2

Name of company

Name of company

Name of product (e.g. investment trust)

Name of product (e.g. investment trust)

Number of units

Number of units

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

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

APIR code (if known)




$

$

Currency if not AUD

Currency if not AUD

Your share

Your share

%

%

If you have more than 2 managed investments, attach a separate sheet with details.

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82 Do you own any managed investments or securities purchased with a margin loan?



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

1

2

Name of margin loan company

Name of margin loan company

Current margin loan balance

Current margin loan balance

$

$

Your share

Your share

%

%

Current portfolio

Current portfolio



If you have more than 2 margin loans, attach a separate sheet with details.

83 In the last 5 years have you given away, sold for less than their market value, or surrendered a right to, any cash, assets, property or income?

Include forgiven loans and shares in private companies.



1

2

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

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

Date given or sold

Date given or sold

What it was worth

What it was worth

/ /

/ /

What you got for it

What you got for it

$

$

Was this gift to a Special Disability Trust (SDT)?

Was this gift to a Special Disability Trust (SDT)?

Your share

Your share

%

%

No

No

Yes

Yes

If you have given away or sold for less than its market value more than 2 items, attach a separate sheet with details.

84 In the last 12 months have you 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 latest statement detailing your margin loan(s) for each investment.

Name of organisation agreement entered into with

Address

Postcode

If you have more than 1 loan, attach a separate sheet with details.

SU016.1707 16 of 25


YOU should answer this question ONLY if you are age pension age or claiming Age Pension.

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

Do you 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.



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

1

2

Name of institution/fund manager

Name of institution/fund manager



$

$

Name of fund

Name of fund

Product reference number


If you have more than 2 superannuation investments, attach a separate sheet with details.


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 allocated pension)• market-linked pension (also known as term allocated

pension)• annuities• defined benefit pension (e.g. ComSuper pension, State

Super pension)• superannuation pension (non-defined benefit).

Do you receive income from any income stream products?



You will need to attach a 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 humanservices.gov.au/forms

1

2

Name of product provider/SMSF/SAF

Name of product provider/SMSF/SAF

Commencement date

Commencement date

/ /

/ /

Type of income stream

Type of income stream



If you have more than 2 income stream products, attach a separate sheet with details.


SU016.1707 17 of 25

87 Do you have any money invested in, or do you receive income from, any other investments not declared elsewhere on this form?

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.



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

1

2

Type of investment

Type of investment

Income received in last 12 months

Income received in last 12 months

$

$

Name of organisation/company

Name of organisation/company

Current value of investment

Current value of investment

$

$

Currency if not AUD

Currency if not AUD

Your share

Your share

%

%

If you have more than 2 investments, attach a separate sheet with details.

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

Include taxi plates, time share, racehorses, greyhounds, investment collections (stamp, coin, wine, art, antiques), travellers cheques, etc.Do NOT include an account used exclusively for funding from the National Disability Insurance Scheme.



1

2

Description of asset

Description of asset

Amount owed

Amount owed

$

$



$

$

Currency if not AUD

Currency if not AUD

Your share

Your share

%

%

If you have more than 2 other assets, attach a separate sheet with details.

89 Do you receive payments from an income protection policy?



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

SU016.1707 18 of 25

90 Do you CURRENTLY receive any income from work other than self-employment?

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

No Go to 92


Attach a copy of the 2 most recent payslips from each employer.

1

2

Employer’s name

Employer’s name

Address

Address

Postcode

Postcode

Phone number

Phone number

( )

( )

Australian Business Number (ABN)


Is this work:

Is this work:

Full-time

Full-time

Part-time

Part-time

Seasonal

Seasonal

Casual

Casual

Personnel, service or clock-card number

Personnel, service or clock-card number

GROSS amount earned per fortnight (before tax and other deductions)

GROSS amount earned per fortnight (before tax and other deductions)

Hours worked per fortnight

Hours worked per fortnight

$ per fortnight

$ per fortnight

per fortnight

per fortnight

Is this your usual wage?

Is this your usual wage?

No

No

Yes

Yes

If you currently get income from more than 2 jobs, attach a separate sheet with details.

91 Do you get any fringe benefits provided by an employer (e.g. use of a car as part of a salary package, rent/mortgage paid)?

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


Yes Attach copies of 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’.

92 In the last 12 months, have you stopped working for any employers (including self-employment)?



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 humanservices.gov.au/forms

1

2

Employer’s name

Employer’s name

Address

Address

Postcode

Postcode

Phone number

Phone number

( )

( )

If you stopped working for more than 2 employers, attach a separate sheet with details.


SU016.1707 19 of 25


Seasonal work is work that is available for part or parts of the year at approximately the same time each year.Contract work is any intermittent work that is performed under a contract for a specific function and/or period including sub-contract work.Intermittent work is work that is available from time to time, can reasonably be predicted to end or not be available for a period, is less than a year in duration and does not accrue leave entitlements.

In the last 6 months have you done any seasonal, contract or intermittent work?


Yes 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 humanservices.gov.au/forms

94 In the last 12 months have you received or expect to receive, any leave entitlements or redundancy payments from an employer?

Include:• annual leave• maternity leave• long service leave or sick leave you received when you

stopped work• entitlements that you cashed in before you stopped work• money in a long-service leave fund or scheme that you

have not cashed in.



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

1 Type of leave entitlement payment

Date paid or payable

/ /

Amount (before tax and other deductions)

Number of working days covered by the payment

$

Employer’s detailsName of business

Address

Postcode

Phone number

( )


Job description



SU016.1707 20 of 25

94 Continued

1 Type of leave entitlement payment

Date paid or payable

/ /

Amount (before tax and other deductions)

Number of working days covered by the payment

$

Employer’s detailsName of business

Address

Postcode

Phone number

( )


Job description

If you have more than 2 entitlements, attach a separate sheet with details.

95 Have you received a redundancy payment in the last 2 years?


Yes Attach documents which confirm any redundancy payments (e.g. letter from employer or Employment Separation Certificate form (SU001)).If you do not have this form, go to humanservices.gov.au/forms

96 Do you receive payments from sources other than Centrelink income support payments?

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



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

1

2

Type of payment

Type of payment

/ /

/ /

Reference number (if known)

Reference number (if known)

Date commenced (if known)


$

$

Who pays it?

Who pays it?

If you receive more than 2 payments, attach a separate sheet with details.


SU016.1707 21 of 25

97 Do you receive payments from an authority or agency outside Australia?

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.



Attach a copy of 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

2

Type of payment

Type of payment

/ /

/ /



Country which pays it?

Country which pays it?

Authority or agency which pays it?

Authority or agency which pays it?

If you receive more than 2 payments from an authority or agency outside Australia, attach a separate sheet with details.

98 Do you receive money from any boarders or lodgers living with you?

Include boarders or lodgers who live with you or in accommodation at the property you live in (e.g. granny flat).Do NOT include immediate family members (son, daughter, parent).



1

2

Name of person

Name of person

Relationship to you

Relationship to you

Number of meals you provide each day

Number of meals you provide each day

/ /

/ /

Amount received per fortnight

Amount received per fortnight



$

$

If you receive money from more than 2 people living with you, attach a separate sheet with details.

99 In the last 12 months, have you received a lump sum payment that you have not already advised on this form?

Do NOT include:• compensation, insurance or damages lump sum payments• funding from the National Disability Insurance Scheme.

Type of lump sum

Who paid it?

/ /

Amount paid Date paid

$

If you have received more than 1 lump sum payment, attach a separate sheet with details.

SU016.1707 22 of 25

100 Do you receive any payments from other sources that you have not already advised us about on this form?

Include:• gratuities• match or sporting payments• other income or payments from other countries• payment in kind, such as non-monetary payments for

services• scholarships, educational assistance or allowance• any other income.Do NOT include • an account used exclusively for funds received from the

National Disability Insurance Scheme• regular gifts received from an immediate family member

(a parent, child, brother or sister).



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

1

2

Type of payment

Type of payment

Who pays it?

Who pays it?

Amount per fortnight

Amount per fortnight

$

$

Your share

Your share

%

%

If you receive more than 2 types of payments, attach a separate sheet with details.


You may be, or have been involved in a trust as:• a trustee• an appointor• a beneficiaryOR have:• made a loan to a private trust• made a gift of cash, assets, or private property to a

private trust in the last 5 years• relinquished control of a private trust in the last 5 years• a private annuity• a life interest• an interest in a deceased estate.A private trust includes a non-complying Self Managed Superannuation Fund or a non-complying Small APRA Fund.

Are you or have you been involved in a private trust in any of the ways detailed above?

No Go to 106

Go to next questionYes

102 Is the private trust now vested?

No Go to 106

Yes You will need to provide a copy of the evidence of the vesting.

103 Have you made any type of gift involving a private trust (either active or vested) in the last 5 years?

No Go to 106


104 Have you told us about this private trust before?


Go to 106Yes

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

No

Yes You will need to complete and attach a Special Disability Trust form (Mod SDT).If you do not have this form, go to humanservices.gov.au/forms

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



SU016.1707 23 of 25


You (or your partner) may be, or have been in the last 5 years:• a director of a company• a shareholder of a companyOR have:• made a loan to a private company• transferred shares in a private company• made a gift of cash, assets or property to a private company.

Are you or have you been involved in a private company in any of the ways detailed above?

No Go to 110


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


Yes You will need to provide a copy of the evidence of deregistration.

108 Have you (and/or your partner) made any type of gift involving a private company (either registered or deregistered) in the last 5 years?

No Go to 110


109 Have you told us about this private company before?

No

Yes

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

Go to next question

Go to next question

110 Are you involved in any type of business?

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


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 humanservices.gov.au/forms

111 Do you have an interest in any other real estate in and/or outside Australia?

No Go to 113


112 How many other properties in and/or outside Australia do you own or have an interest in?

You will need to complete and attach a Real estate details form (Mod R) for each property. If you do not have these forms, go to humanservices.gov.au/forms


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.

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


Go to 115Yes

114 Are you RECEIVING or have you EVER BEEN PAID compensation, insurance and/or damages?

No Go to 116


115 Have you told us about these payments before?

No

Yes

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

Go to next question

Go to next question

116 Please read this before answering the following questions.

You are not breaking the law if you do not give us your tax file number, but if you do not provide it, or authorise us to get it from the Australian Taxation Office, you may not be paid.In giving us your tax file number in relation to this claim you authorise us to use your tax file number for other social security payments and services in future where necessary.

No

Not sure

Yes

Go to next question

Go to next question

Go to 118

Have you given us your tax file number before?





SU016.1707 24 of 25

117 Do you have a tax file number?

No Please call us on 132 850.

Your tax file numberYes


If your only income for this financial year is the payment you are now claiming, you may not have to pay any tax.However, you may have to pay tax if you get any other income this financial year, such as salary or wages.If you think you will have to pay tax this year, you can ask us to deduct tax instalments from your payment. You can change this at any time.If you are not sure how much tax to have taken out of your payment, contact the Australian Taxation Office.

Do you want tax taken out of your payment?


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

Amount (must be in whole dollars)

Percentage (%) of taxable payment

OR

Yes

$ .00 per fortnight % per fortnight

119 Which of the following forms, documents and other attachments are you providing with this form?If you are not sure, check the question to see if you should attach 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.

Identity documents (For a list of acceptable documents, refer to

Confirming your identity, in the Information Booklet)

Proof of employment(If you answered No at question 6)

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

(If you answered Yes at question 15)

Documents showing balances for bank, building society and credit union accounts(required at question 16)

Copy of the Death certificate (if available)(required at question 18)

Relationship Details Separated Under One Roof form (SS293)


Proof of your Australian residence status(If you answered No at question 23)

Real estate details form (Mod R)(If you answered Yes at question 38 or 39)

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


Copies of documents to verify the details of the entry agreement for daily fees

(If you answered No at question 48)

Copy of accommodation payment agreement(If you answered Yes at question 49)

Copy of document to verify the details of your entry contribution


Full copy of your signed lease or tenancy agreement(If you answered Yes at question 69)

Documents showing balances for bank, building society and credit union accounts

(if required for question 73)

Copy of Insurance policy documents and latest statements(If you answered Yes at question 74)

Copy of investment bond/debenture document(s)(If you answered Yes at question 75)

Copy of funeral bond contract(s)(If you answered Yes at question 77)

Copy of money on loan document(s) (if available)(If you answered Yes at question 78)

Copy of share certificate(s) or latest statement for each shareholding LISTED on a stock exchange


Copy of share certificate(s) or latest statement for each shareholding NOT Listed on a stock exchange


Copy of managed investment certificate(s) or similar document(s)


Copy of latest statement detailing your margin loan(s) for any managed investments or securities


Copy of the loan agreement or contract(If you answered Yes at question 84)

Latest statements for retirement savings accounts and superannuation funds, financial statement including income tax return and member statement for SMSF and SAF funds


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


Copy of document(s) with details of investment(s)(If you answered Yes at question 87)

Copy of the policy document and latest statement for the income protection policy


Copy of the 2 most recent payslips from each employer(If you answered Yes at question 90)

Copies of Fringe Benefit details(If you answered Yes at question 91)

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


Seasonal, Contract and Intermittent Work Details form (SU496)


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


119 Continued

Continued

SU016.1707 25 of 25

120 IMPORTANT INFORMATION

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 humanservices.gov.au/privacy

121 Statement

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

correct.• I will notify the Australian Government Department of Human

Services of any changes to this information, within 14 days after the change(s) occur(s).

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.

• I may need to provide further information if required.• giving false or misleading information is a serious offence.• the Australian Government Department of Human Services

can make relevant enquiries to make sure I receive the correct entitlement.

Your signature

Date

/ /

OFFICE USE ONLY

CRN

Date of receipt

/ /

119 ContinuedDocuments which confirm redundancy payments OR

Employment Separation Certificate form (SU001) (If you answered Yes at question 95)

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


Copy of document(s) with details of payments by authorities or agencies outside Australia


Copies of the most recent statements/certificates with details of other payments


Copy of evidence of the vesting of the private trust(If you answered Yes at question 102)

Private Trust form (Mod PT)(If you answered No at question 105)

Special Disability Trust form (Mod SDT)(If you answered Yes at question 105)

Copy of evidence of the deregistration of the private company


Private Company form (Mod PC)(If you answered No at question 109)

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


Real estate details form (Mod R) for each property(required at question 112)

Compensation and damages form (Mod C)(If you answered No at question 115)

http://www.humanservices.gov.au/privacy