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SA468.1807 Notes—1 of 12
Information you need toknow about your claim for
Sickness AllowanceSickness Allowance may be paid if you are temporarily unable to work or study due to a disability, illness or injury and are:• aged 22 or over but under age pension age and have a job to return to, or• aged 22 or over but under age pension age and receiving ABSTUDY, or• aged 25 or over but under age pension age and receiving Austudy.
You must have work or study to return to when you are better.
Online services Use our online services
You do not need to complete this form if you use our online services. Claiming online is faster.
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 www.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.
For more information Go to www.humanservices.gov.au/sicknessallowance or call us on 132 717 or visit one of our service centres.
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 Freecall™ 1800 810 586. A TTY phone is required to use this service.
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.
Keep these Notes (pages 1 to 12) for your information.
SA468.1807 Notes—2 of 12
Information in other languages
SA468.1807 Notes—3 of 12
Contents
Payment 4Sickness Allowance 4
Payment information 4Additional information required 4Australian residence requirements 4Income and assets 5The income test 5Preclusion Periods 5The assets test 6Asset hardship provisions 7Compensation 7
Someone to deal with us for you 8Nominees and other arrangements 8
Definition of a partner 8
Confirming your identity 8
Changes you must tell us about 11
Other payments, concessions and help 11Helpful publications and information 12
SA468.1807 Notes—4 of 12
Payment
Sickness Allowance Sickness Allowance may be paid if you are temporarily unable to work or study due to a disability, illness or injury and are:
• aged 22 or over but under age pension age and have a job to return to, or• aged 22 or over but under age pension age and receiving ABSTUDY, or• aged 25 or over but under age pension age and receiving Austudy.
You must have work or study to return to when you are better.
A Medical Certificate from a medical practitioner must be supplied when claiming Sickness Allowance. The certificate must state:
• the practitioner’s diagnosis (the name or description of the condition), and• the practitioner’s prognosis (how long the symptoms will affect your ability to work or study), and• that you are incapacitated for your usual work or study, and• the period for which you are incapacitated for your usual work or study.
You must attach an approved Medical Certificate completed by your treating doctor. Your doctor will be able to provide you with this Medical Certificate.
A certificate which is not on the approved form can be accepted if all the necessary information is included.
Payment information
Additional information required
When we are processing your claim we may need extra information. We may call or write to you, or we may ask you to come to one of our service centres for an interview or to attend an Employment Services Assessment.
Australian residence requirements
To be eligible for Sickness Allowance, you must be an Australian resident and in Australia when you lodge your claim. To remain qualified for these payments you must also remain an Australian resident.
You are an Australian resident (as defined by the Social Security Act 1991) if you are living in Australia and you are either:
• an Australian citizen, or• a permanent visa holder, or• a protected Special Category visa holder, that is, you arrived in Australia on a New Zealand passport
and you were in Australia on 26 February 2001, or for 12 months in the 2 years immediately before this date, or were assessed as ‘protected’ before 26 February 2004.
If you are a non-protected Special Category visa holder, you may be entitled to receive either Newstart Allowance, Sickness Allowance or Youth Allowance. At the time of making a claim you must have been living in Australia continuously for at least 10 years. Time spent in Australia before 27 February 2001 cannot count towards these 10 years. If you are eligible, payment can be made for a maximum continuous period of up to 6 months.
In deciding whether you are living in Australia, we may need to look at the nature of your accommodation, the nature and extent of family relationships in Australia, the nature and extent of employment, business or financial ties with Australia, the frequency and duration of travel outside Australia and any other relevant matters.
SA468.1807 Notes—5 of 12
Payment information • continued
Newly arrived residents generally have a 104 week waiting period for Sickness Allowance. This may not apply to you if you:
• are an Australian citizen, or• arrived under a refugee or humanitarian program, or• hold a certain visa subclass, or• are the partner of a refugee, former refugee or humanitarian migrant, and were the partner of that
person at the time they arrived in Australia.
For more information, go to www.humanservices.gov.au/newresidentswaiting
Income and assets How much payment you receive will depend on your circumstances and your (and/or your partner’s) income and assets.
We calculate the amount that could be paid to you and, if applicable, to your partner under both the income test and the assets test. The test giving the lower rate of payment is the one used to pay you (and/or your partner).
The income test Income includes money received from employment and money deemed to be earned from investments. It also includes money from outside Australia.
You can have income up to certain amounts before your payment is reduced.
Your income may include:• deemed income from financial investments
• gross income from earnings
• income received to provide care
• net income from business, including farms
• family trust distributions or dividends from private company shares
• income attributable to the controllers of a private trust or private company
• income from rental property
• income from a life interest
• income from boarders and lodgers (other than immediate family)
• superannuation and pensions from countries other than Australia
• income from income stream products, such as superannuation pensions and annuities.
Funding you, your partner or children receive from the National Disability Insurance Scheme does not need to be included.
Your rental income may be exempt if you have entered an aged care home, pay an accommodation bond by periodic instalment and rent out the home you left to enter care.
For more information about income, go to www.humanservices.gov.au/income
Preclusion Periods Income Maintenance Period
If you receive or are going to receive leave entitlements or redundancy payments from your work, including annual leave, long service leave, sick leave and maternity leave, you may be required to serve a waiting period before you are entitled to payment. Income maintenance periods generally apply from the date the leave or redundancy payments are received, for the period covered by the payment.
Continued
SA468.1807 Notes—6 of 12
Payment information • continued
Seasonal Work Preclusion Period
If you (or your partner) have done seasonal, intermittent or contract work in the previous 6 months before lodging a claim and earned a higher than average income, you may have to wait an additional period before being paid.
Liquid Assets Waiting Periods
If you have funds over a certain amount you may be required to serve a waiting period before you are entitled to payment.
The assets test Most things you own have a value and can be counted as assets. This includes assets held outside Australia. For the purpose of calculating your payment, the value of your assets is what you would get for them if you sold them.
Generally, any debt owing on an asset is deducted from the value of the asset.
Your assets may include:
• rental properties, farms, second or holiday houses
• cars, caravans, boats or trailers
• home contents and personal effects, including antiques or other collectables
• the market or trade value of all savings and investments, including funeral bonds
• loans you have made to other people, family trusts and companies
• value of most income stream products
• business assets
• interest in a private trust or private company
• superannuation investments held by people over age pension age
• licences (e.g. fishing or taxi)
• surrender value of life insurance policies, and• any assets given away or sold for less than their market value within the last 5 years.
The following assets are NOT included:
• your principal family home (and up to 2 hectares of privately used surrounding land that is on the same title document as the home), and any permanent fixtures such as wall-to-wall carpet and wall heaters
• some income stream products
• cemetery plots and pre-paid funeral expenses
• any property or monies left to you in an estate which you are not yet able to receive, generally for a period up to 12 months
• accommodation bonds paid to an aged care home or on entry to residential aged care
• aids for people with a disability
• monies received from the National Disability Insurance Scheme to provide for the needs of people with a disability
• most compensation or insurance payments for loss or damage to buildings or personal effects
• any life interest, reversionary interest, remainder interest or contingent interest unless it was created by you, your partner or at the time of death of your partner, and
• assets up to a certain limit held in a Special Disability Trust (SDT) for an immediate family member.
These are called exempt assets.
For more information about assets, go to www.humanservices.gov.au/assets
SA468.1807 Notes—7 of 12
Payment information • continued
Asset hardship provisions
You can apply for hardship assistance if you are experiencing severe financial hardship and have little or no entitlement to a payment.
You may be considered in severe financial hardship if:
• your total income including any payment paid under the assets test is less than the maximum rate of that payment
• your readily available funds are less than the allowable limit, and• there is no other course of action which you could be expected to take to improve your financial
position.
You may be considered in severe financial hardship if you receive a pension and:
• your pension is reduced or not payable because of the assets test
• you own an asset which you cannot sell or be reasonably expected to sell
• you cannot borrow against the asset or be reasonably expected to borrow against the asset
• you would otherwise qualify for a payment under the income test
• the gifting rules do not apply or can be disregarded.
You may be considered in severe financial hardship if you receive an allowance or benefit and:
• your allowance or benefit is not payable because of the assets test
• you own an asset which you cannot sell
• you cannot borrow against the asset
• the asset is on the market to be sold at a realistic price
• you are unable to qualify for any other Australian Government assistance
• you would otherwise qualify for payment under the income test
• the gifting rules do not apply or can be disregarded.
Compensation What to do before you accept a compensation payment
If you have an injury or illness that is the subject to a compensation claim, payments and benefits you receive from Centrelink may be affected. To work out how the proposed lump sum may affect your payments, you or your solicitor can take advantage of our compensation online estimator. To access the estimator, go to www.humanservices.gov.au/centrelinkcompensationrecovery
What if you receive regular compensation payments?
If you get regular compensation payments (such as workers’ compensation) and you apply for Centrelink payments, your Centrelink payments can be reduced by a dollar for every dollar of compensation payment. However, if you were receiving a Centrelink payment at the time of your accident, your regular compensation payments will be treated as ordinary income. If you are a member of a couple, the compensation may reduce your partner’s rate using the income test applying to their Centrelink payment.
Lump Sum compensation payments
If you get a lump sum compensation payment, which contains an amount for economic loss, we will work out a period, called a ‘preclusion period’, during which a person cannot get payments from us. The preclusion period can be in the past, in which case all Centrelink payments received during the period must be paid back or in the future, in which case no payments can be made until the period is over, or both. If you receive a lump sum compensation payment, your partner will not be affected by the preclusion period and can still receive Centrelink payments provided they are eligible.
SA468.1807 Notes—8 of 12
Someone to deal with us for you
Nominees and other arrangements
Some customers have difficulty managing their affairs often because of a disability or illness, problems with reading, writing or understanding information or difficulty handling money.
If you need help dealing with us, a Person Permitted to Enquire (PPE) or Nominee Arrangement is available.
Person Permitted to Enquire arrangements allow you to authorise a person or organisation to make limited enquiries only about your record.
A Person Permitted to Enquire is not a Nominee Arrangement.
A Nominee Arrangement authorises a person or organisation to enquire, act and make changes on your behalf and/or receive your payment on your behalf.
If you want to request either of these arrangements, complete the Authorising a person or organisation to enquire or act on your behalf form (SS313). If you do not have this form, go to www.
humanservices.gov.au/nominees or call us on 132 717.
Definition of a partner
Under social security and family assistance law, a person is considered to be your partner if you and the person are:
• married, or• in a registered relationship, or• in a de facto relationship,
and you and the person are not living separately and apart on a permanent or indefinite basis.
Note: Two people not physically living together can still be considered a member of a couple.
We generally consider a person to be in a de facto relationship from the time they commence living with another person as a member of a couple.
For more information, go to www.humanservices.gov.au/moc
Confirming your identity
As a customer you may be required to confirm your identity when claiming a payment or service from the Australian Government Department of Human Services.
In most cases, you will only need to confirm your identity once in order to access payments and services across the department. You must confirm your identity by providing original documents (not copies) from the approved list below.
We need you to provide one document from each of the following three categories, one of which should be a photographic identity document:• 1 Commencement of Identity document, and• 1 Primary Use in Community document, and• 1 Secondary Use in Community document.
Continued
SA468.1807 Notes—9 of 12
Confirming your identity • continued
Where possible, the department will request your consent to verify the documents you provide.
Note: An identity document cannot be used multiple times (e.g. a document used as Commencement of Identity, cannot be used again as a Primary or Secondary Use in Community document).
If you are known by a name different to that on your Commencement of Identity document, you will need to provide a valid name change document (i.e. Marriage certificate or legal change of name certificate).
If you have difficulty in obtaining or providing these documents, please contact us as soon as possible.
Commencement of Identity in AustraliaDocument Explanation/descriptionAustralian Birth Certificate A full Australian birth certificate issued in your name/former name.
Cannot accept: birth extracts or birth cards.
Australian Visa Australian visa, current at time of entry to Australia as resident or tourist, issued in your name/former name.
Australian Citizenship Certificate Australian citizenship or citizenship by descent certificate issued in your name/former name.
ImmiCard A photo identity card issued in your name/former name by the Department of Home Affairs (Home Affairs) that assists the cardholder to prove their visa/migration status and enrol in services.
Australian Passport (current) A current Australian passport in your name/former name. Cannot accept: expired passports.
Certificate of Identity Certificate of Identity issued in your name/former name by the Department of Foreign Affairs and Trade (DFAT) to refugees and non Australian citizens for entry to Australia.
Certificate of Evidence of Resident Status
Certificate of Evidence of Resident Status issued in your name/former name.
Document of Identity Document of Identity issued in your name/former name by the Department of Foreign Affairs and Trade (DFAT), to Australian citizens or persons who possess the nationality of a Commonwealth country, for travel purposes.
Note: The above documents can also be used to satisfy Primary or Secondary Use in Community (if not already used as Commencement of Identity).
Primary Use in CommunityDocument Explanation/descriptionAustralian Driver Licence – Motor Vehicle
Current state or territory issued driver licence, learner permit or provisional licence showing signature and/or photo and same name as claim.
Australian Marriage Certificate Marriage certificate issued by a state or territory government agency. Cannot accept: church or celebrant issued certificates.
Passport issued outside Australia Current passport issued by a country other than Australia, with a valid entry stamp or visa.
Proof of Age Card Current proof of age or photo identity card issued by a government agency in your name with photo and/or signature.
Shooter or Firearm Licence Current shooter or firearm licence showing signature and/or photo and same name as claim. Cannot accept: minor or junior permit and/or licence.
Student ID Card Current secondary student ID card issued in your name with photo and/or signature. Note: For persons aged under 18 years with no other Primary Use in Community only.
Note: The above documents can also be used to satisfy Secondary Use in Community (if not already used as Primary Use in Community).
SA468.1807 Notes—10 of 12
Confirming your identity • continued
Secondary Use in CommunityDocument Explanation/descriptionSecurity Licence Current security protection industry or crowd control licence, showing signature and/or photo and
same name as claim.
Bank/Financial Institution Card, statement or passbook
Current ATM, credit or debit card showing your name and signature. Statement or passbook from current savings or cheque account showing your name and same address (if applicable) as your claim. Cannot accept: cards issued by organisations other than banks, credit unions or building societies, ATM or internet receipts/statements or account documentation issued by banks/financial institutions outside Australia.
Child’s Birth Certificate Australian birth certificate for a child showing your name as parent/guardian. Cannot accept: sibling’s certificate.
Defence Force Identity Card Identity card issued by the Australian Defence Force, showing same name as claim, and photo or signature.
Australian Divorce Papers Australian divorce papers in your name/former name (e.g. Decree Nisi, Decree Absolute).
Educational Certificate Educational qualification certificate in your name/former name (school/TAFE/university/Registered Training Organisation [RTO]).
Certified Academic Transcript Certified academic transcript from an Australian university in your name/former name.
Mortgage Papers Legally drawn mortgage papers for an Australian residence in your name/former name.
Name Change Legal change of name certificate or deed poll certificate.
Veterans’ Affairs Card Current Department of Veterans’ Affairs card issued in your name.
Tenancy Agreement or Lease Current formal residential tenancy agreement or lease in your name and showing same address as claim.
Motor Vehicle Registration Current motor vehicle registration showing your name, same address as claim and proof of payment.
Foreign Government issued Documents
Documents issued by a country other than Australia (comparable to Australian issued documents), including foreign birth, marriage and education certificates, lapsed foreign passports, foreign driver licences and overseas national identity cards.
Australian Government issued photo ID Card
Current Commonwealth, state or territory issued photo identification card issued in your name.
Rates Notice Paid rates notice in your name and showing same address as claim, less than 12 months old.
Utility Account A paid utility account (e.g. gas, water, electricity or phone) in your name and showing receipt number and same address as claim, less than 12 months old.
Student ID Card Current student ID card issued in your name with photo and/or signature (secondary/TAFE/university/ Registered Training Organisation [RTO]).
Electoral Enrolment Proof of electoral enrolment card issued in your name and same address as claim.
Aviation Security Identity Card (ASIC) Current aviation security identity card showing same name as claim, photo and/or signature.
Maritime Security Identification Card Current maritime security identification card showing same name as claim, photo and/or signature.
Police Identity Card Current police identity card showing same name as claim, photo and/or signature.
Prison release certificate A prison release certificate in your name with a photo and/or signature. Note: Certificates that do not meet this criteria cannot be used.
Tangentyere Community Card Current proof of identity card issued by Tangentyere Council showing same name as claim and photo.
SA468.1807 Notes—11 of 12
Changes you must tell us about
You can tell us about changes to your circumstances through online services, if you have a myGov or Centrelink online account. For more information, see ‘Online services’ on page 1.
Travelling outside Australia If you receive Sickness Allowance, you should tell us if you are going overseas and:
• you plan to live in another country
• you are travelling on a cruise ship
• you are leaving due to an acute family crisis, for medical treatment overseas, for humanitarian reasons or to attend a training camp with the Defence Force Reserves
• you are receiving payment under a residence exemption available to New Zealand citizens, or• your dependent child will be away for longer than 6 weeks
There is further information available at www.humanservices.gov.au/paymentsoverseas about how your payment or concession card may be affected or whether you should tell us you are leaving or returning to Australia. You can also contact us if you want to find out more information.
Other payments, concessions and help
Advance Payments Customers can apply for an Advance Payment which is a lump sum amount paid from part of your future payment. It can help you pay larger expenses or bills which you do not have enough money for. The Advance Payment is recovered, interest free, from your payments over 13 fortnights.
The Advance Payment is limited by maximum and minimum amounts which depend on the rate of payment you receive.
The number of Advance Payments you can receive over a 12 month period will depend on the type of payment that you receive and whether you are eligible.
Carer Payment and Carer Allowance
If someone provides constant care in your home they may be able to claim Carer Payment through us.
If someone provides daily care either in your home or the carer’s home, they may be able to claim Carer Allowance. For more information, go to www.humanservices.gov.au/carers
Information you need to know about your claim for Carer Payment and Carer Allowance (Ci002) (Information Booklet) is a booklet with information about claiming Carer Payment or Carer Allowance. For a copy, go to www.humanservices.gov.au
Centrepay Centrepay is a voluntary bill-paying service which is free for Centrelink customers. Use Centrepay to arrange regular deductions from your Centrelink payment to pay bills and expenses like rent, gas, electricity, water and phone, as well as other household costs. You can start or change a deduction at any time. The quickest way to do this is through your Centrelink account online.
Child Dental Benefits Schedule You may also be eligible for assistance under the Child Dental Benefits Schedule. For more information, go to www.humanservices.gov.au/childdental
Community EngagementOfficers
Community Engagement Officers may be able to visit you if you are homeless, living in a hostel or refuge, suffering from a mental illness or fleeing from domestic violence. Community Engagement Officers can tell you about payments and services and help you access these services. They provide services in locations like rehabilitation centres, psychiatric hospitals, prisons, hostels, drop-in centres.
SA468.1807 Notes—12 of 12
Other payments, concessions and help • continued
Financial InformationService Officers
Financial Information Service (FIS) Officers can give you free, independent information. This will help you understand investments and how they work, and help you make better financial decisions.
For more information, go to www.humanservices.gov.au/fis
Health Care Card If you get Sickness Allowance, you will automatically get a Health Care Card.
A Health Care Card provides you access to pharmaceutical medications listed under the Pharmaceutical Benefits Scheme at a reduced cost. You may also receive other concessions provided by state and territory governments.
Indigenous Services Staff Indigenous Services Staff are located in most service centres. Some service centres also have interpreters who speak Aboriginal or Torres Strait Islander languages and teams who visit and help remote communities.
Pharmaceutical Allowance Pharmaceutical Allowance provides financial assistance to help purchase prescription medicines. A separate claim for Pharmaceutical Allowance is not required. Pharmaceutical Allowance forms part of the rate payable to people in receipt of Sickness Allowance.
Remote Area Allowance Remote Area Allowance was introduced as an additional assistance for customers in remote areas. It recognises that many customers who do not pay tax, or very little tax, do not get the full benefit of tax zone rebates. Remote Area Allowance makes a contribution towards some of the costs associated with living in particularly remote areas.
Rent Assistance You may be eligible for Rent Assistance if you rent your accommodation in the private rental market. This includes paying private rent, board or lodging for accommodation in a house, flat or unit, boarding house, hostel or private hotel. It also includes paying ground rent, site fees or mooring fees for a caravan, mobile home or boat in which you live.
Rent Deduction Scheme The Rent Deduction Scheme allows customers in public housing to have their housing payments (such as rent, loan repayments and arrears) deducted from their payments and sent directly to the Housing Authority in their state or territory.
Social Workers We have professional social workers in our service centres and Smart Centres throughout Australia. Social workers can offer you personal counselling and support in difficult times, such as domestic and family violence, severe financial hardship, homelessness, loss and bereavement. They can refer you to other services and programs like housing, health, emergency relief, legal and/or counselling services and support groups.
Helpful publications and information
If you would like to know what correspondence and publications may be available in alternative formats, you can call us on 132 717.
Compensation kit Contains information about compensation rules. You or your solicitor should go to www.
humanservices.gov.au/business/publications/co297 or call us on 132 717 and ask for your nearest Compensation Recovery Team for further information.
Essential Medical Equipment Payment
If you, or someone you care for, use essential medical equipment or medically required heating/cooling in your current residence, you may be eligible for the Essential Medical Equipment Payment. For more information about how to claim, go to www.humanservices.gov.au/emep or call us on 132 468.
SA468.1807 1 of 23
Claim forSickness Allowance
When to use this form
What else you may need to provide
Use this form if you are claiming:
Sickness Allowance
A payment for people who are temporarily unable to work or study due to a disability, illness or injury and are:
• aged 22 years or over but under age pension age and have a job to return to, or• aged 22 years or over but under age pension age and receiving ABSTUDY, or• aged 25 years or over but under age pension age and receiving Austudy.
You must have work or study to return to when you are better.
You may need to provide identity documents. For a list of acceptable documents, refer to Confirming your identity in the Notes Booklet.
Online services Use our online services
You do not need to complete this form if you use our online services. Claiming online is faster.
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.
Forms in your claim pack
In your claim pack, you should have the following:
• Claim for Sickness Allowance form (SA468)
• Income and Assets form (SA369)
For more information Go to humanservices.gov.au/sicknessallowance or call us on 132 717 or visit one of our service centres.
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.
How to claim You must attach an approved Medical Certificate completed by your treating doctor.
Your doctor will be able to provide you with this Medical Certificate.
Complete the claim form and any additional forms required. You may choose to use an accountant or financial adviser to complete your Income and Assets form (SA369) but you must sign it. If you need other people to complete forms, make sure you give them the forms as soon as possible.
SA468.1807 2 of 23
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SA468.1807 3 of 23
9 Your date of birth
/ /
7 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)?
12
11
Your postal address (if different to above)
Your permanent address
Postcode
Postcode6 Your name
Family name
First given name
Second given name
OtherMr Mrs MsMiss
8 Your genderMale
Female
1
2 Do you need an interpreter when dealing with us?
Are you unable to work or study for more than 2 years because of a disability, illness or injury?
This includes an interpreter for people who have a hearing or speech impairment.
Go to 5
Go to next question
No
No
No
Yes
Yes
Yes
Go to next question
Give details below
3 What is your preferred spoken language?
4 What is your preferred written language?
You will need to complete a claim for Disability Support Pension. If you do not have this form, call us on 132 717.
Do NOT continue with this claim.
1 Other name
Type of name (e.g. name at birth)
If you have more than two other names, attach a separate sheet with details.
2 Other name
Type of name (e.g. maiden name)
Go to next question
5 Do you want to authorise another person or organisation to make enquires, get payments and/or act on your behalf?
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
10 Your Centrelink Reference Number (if known)
• 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.
Filling in this form
CLK0SA468 1807
SA468.1807 4 of 23
13
14
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 www.
humanservices.gov.au/em or visit one of our service centres.
Question 14 will help us work out if you are eligible for Telephone Allowance.
Please read this before answering the following question.
Please read this before answering the following questions.
Home phone number
Your contact details
Whose name is the home phone account in?
Whose name is the mobile phone account in?
Is this a silent number?
Is this a silent number?
No
No
Yes
Yes
Mobile phone number
Fax number
Work phone number
Alternative phone number
( )
( )
( )
( )
My name
My name
Another name
Another name
My partner’s name
My partner’s name
Not applicable
Not applicable
15 Questions 15 and 16 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
16 Are you of Australian South Sea Islander origin?No
Yes
17 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)
Branch where the account is held
Account number (this may not be
your card number)
Account held in the name(s) of
4 of 23
@
SA468.1807 5 of 23
18 Please read this before answering the following question.
Select ONE option below that best describes your current relationship status.
If you have ever been separated, list the date that you most recently reconciled with your partner.
If you have ever been separated, list the date that you most recently reconciled with your partner.
What is your CURRENT relationship status?
Married Go to 19
Registered relationship(relationship registered under state or territory law) Go to 19
Partnered(living together in a relationship, including de facto) Go to 20
Separated(previously lived with a partner, including in a marriage, registered or de facto relationship) Go to 27
Divorced Go to 27
Widowed(previously partnered, including in a marriage, registered or de facto relationship) Go to 26
Never married or lived with a partner Go to 36
19
20
What is your date of marriage or relationship registration?
When did you and your partner start living together as a member of a couple?
/ /
21 Do you currently live in the same home as your partner?Go to next question
Go to 29
No
Yes
Go to 21/ /
23
22
Your partner’s postal address (if different to above)
Your partner’s permanent address
Postcode
Postcode
24 Why are you not living with your partner?
Partner’s illness
Your illness
Partner in prison
Partner’s employment
Other Give details below
Go to 29
25 Period not living with your partner
From
To
/ /
OR indefinite/ /
26 Please give the following details about your deceased partner.
Full Name
Date of birth Date of death
Go to 35
/ // /
27 Do you live in the same home as your former partner?
SS293
Go to next question
Go to 35
No
28 Please give the following details about your former partner.
29 Your partner’s name
Family name
First given name
Second given name
OtherMr Mrs MsMiss
Full name
Date of birth
/ /
Date relationship ended
/ /
Current address (if known)
Go to 35
Postcode
Yes
SA468.1807 6 of 23
32 Your partner’s date of birth
/ /
30 Has your partner ever used or been known by any other name (e.g. name at birth, maiden name, previous married name, Aboriginal or tribal name, alias, adoptive name, foster name)?
31 Your partner’s genderMale
Female
Go to next questionNo
Yes Give details below
1 Other name
Type of name (e.g. name at birth)
If your partner has more than two other names, attach a separate sheet with details.
2 Other name
Type of name (e.g. maiden name)
33 Your partner’s Centrelink Reference Number (if known)
34
35
36
Do you give permission for your partner to discuss your payments with us?
You can change this authority at any time.
Are you married, in a registered relationship or partnered (including de facto)?
Do you share your accommodation with anyone other than an immediate member of your family?
Go to next question
Go to next question
Go to 38
Go to 38
Go to 38
No
No
No
Yes
Yes
Yes
37 Please read this before answering the following questions.
The following questions are to be completed if you share your accommodation with anyone other than an immediate family member.This includes anyone who:• regularly stays any number of nights per week• uses your home as a base (e.g. truck drivers, miners, flight
attendants or members of the armed forces).We need some details about your living arrangements to work out your correct payment.The questions on this form will assist us to decide whether we need additional information.
Give details of each person who shares your accommodation. Do not include immediate family members.
Person 1 Name Age
Gender
Male Female
When did you start sharing with this person?
What is your relationship to this person?
Have you shared accommodation, at another address, with this person?No
Yes
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?
Give details below
Give details below
SS293
No
Yes
SS284
No
Yes
SS284
No
Yes
SS284
No
Yes
Are you concerned about your safety if forms are issued to this person?
No
Yes
SA468.1807 7 of 23
Continued 38 In the last 14 days, have you received or claimed any of the following payments (not including Family Tax Benefit)?
• ABSTUDY• Austudy• Carer Payment• Disability Support Pension
– including pension for permanently blind
• Newstart Allowance
• Parenting Payment – single, or – partnered
• Partner Allowance• Sickness Allowance• Special Benefit• Widow
Allowance/Pension• Wife Pension• Youth Allowance.
Go to next question
Go to 52
No
Yes
39
41 Are you an Australian citizen who was born in Australia?
Go to 51
No
Yes
40 Have you EVER travelled outside Australia, including short trips and holidays?
This question will help us to verify your Australian residence.
Year you last entered Australia
Passport number
Country of issue
42 What is your country of birth?
If you share with more than two other people, attach a separate sheet with details.
Person 2 Name Age
Gender
Male Female
When did you start sharing with this person?
What is your relationship to this person?
Have you shared accommodation, at another address, with this person?No
Yes
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?
Give details below
Give details below
SS293
No
Yes
SS284
No
Yes
SS284
No
Yes
SS284
No
Yes
Are you concerned about your safety if forms are issued to this person?
No
Yes
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
Go to next question
Give details below
SA468.1807 8 of 23
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?
47
46
48
49
43
Did you start living in Australia before 1965?
Has your visa changed since you arrived in Australia?
Are you a refugee or former refugee?
Did your partner or either of your parents arrive on a refugee or humanitarian visa?
What is your country of citizenship?
Go to next question
Go to next question
Give details below
Most recent visa details
44 What type of visa did you arrive on?
New Zealand passport (Special Category visa)
Go to 47
Permanent
Temporary
Not sure
Go to next question
Go to next question
Go to 47
No
No
No
No
Yes
Yes
Yes
Yes
45 Your visa details on arrivalVisa sub class
Visa sub class
Date visa granted
/ /
Date visa granted
/ /
51 Please read this before answering the 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 require 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
50 Did someone provide you with an Assurance of Support for your migration to Australia?
No
Not sure
Yes
Australia
Other Give details below
Date granted
/ / Go to 44
Country of citizenship
Date granted
/ /
Country Date from
/ /
/ /
/ /
/ /
/ /
/ /
53 In the last 14 days has your partner received or claimed any of the following payments (not including Family Tax Benefit)?
• ABSTUDY• Age Pension• Austudy• Carer Payment• Disability Support Pension
– including pension for permanently blind
• Newstart Allowance
• Parenting Payment – single, or – partnered
• Partner Allowance• Sickness Allowance• Special Benefit• Widow
Allowance/Pension• Wife Pension• Youth Allowance.
Go to next question
Go to next question
Go to 63
No
Yes
54
52 Do you have a partner?
Do not answer questions 53 to 62. Go to 63
No
Yes
What country is your partner currently living in?
The country of residence is where your partner normally lives on a long term basis.
Australia
Other
Go to next question
Country of residence
SA468.1807 9 of 23
56 Is your partner an Australian citizen who was born in Australia?
Go to 62
No
Yes
55 Has your partner EVER travelled outside Australia, including short trips and holidays?
This question will help us to verify your partner’s Australian residence.
Year your partner last entered Australia
Passport number
Country of issue
57 What is your partner’s country of birth?
58
60 What type of visa did your partner arrive on?
New Zealand passport (Special Category visa)
Go to 62
Permanent
Temporary
Not sure
Go to next question
Go to next question
Go to 62
61 Your partner’s current visa detailsVisa sub class Date visa granted
/ /
No
Not applicable – never travelled to Australia
Yes
Go to next question
Go to next question
Give details below
What is your partner’s country of citizenship?
Australia
Other Give details below
Date granted
/ / Go to 60
Country of citizenship
Date granted
/ /
59 Has your partner ever lived in Australia?
No Go to 63
Yes Go to next question
Go to next question
62 Please read this before answering the question.
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
If you require more space, attach a separate sheet with details.
List ALL countries your partner has lived in since birth and the date they started living in each country.
Include when your partner started living in AUSTRALIA.
Do NOT include short trips or holidays.
No
Yes
Country Date from
/ /
/ /
/ /
/ /
/ /
/ /
SA468.1807 10 of 23
Child 1
If you have more than two children in your care, copy and attach pages 10 and 11 for each additional child before completing the details for child 1.
63 Do you provide care for any child(ren) under 18 years of age or full-time students under 22 years of age?Go to 79 on page 14
Give the following details of each child
No
Yes
64
65
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
67
68
66
Date of birth
What is this child’s country of birth?
/ /
GenderMale
Female
69
Passport number
Country of issue
Has this child EVER travelled outside Australia, including short trips and holidays?
This question will help us to verify this child’s Australian residence.
Which of the following best describes your relationship to this child?
70 Please read this before you answer the question.
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.
Give details below
Parent
Grandparent
Step-parent
Foster carer
Other
71 Does this child currently live with you?
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
What is the percentage of your (or your partner’s) care of this child?
No
No
Yes
Yes
72
%
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?
Go to next question
Go to 77
Give details below
Go to next question
No
No
No
Yes
Yes
Yes
73
74
75
Year this child last entered Australia
No
Not applicable – never travelled to Australia
Yes
Go to next question
Go to next question
Give details below
SA468.1807 11 of 23
Child 1
No
Yes
Go to 79 on page 14No
Yes
78 Do you provide care for another child under 18 years of age or full-time students under 22 years of age?
77 Do you receive Family Tax Benefit for this child?
If you have more than two dependent children, (if you have not already copied pages 10 and 11) copy and attach pages 12 and 13 for each additional child before completing the details for child 2.
Go to next question on the next page
Attach proof of birth or adoption (e.g. birth certificate or adoption papers) for this child if you have not previously provided it to us.
Go to next question
Go to next question
Continued
Does this child have any income?Go to next question
Amount
No
Yes
76
$ per week
SA468.1807 12 of 23
Child 2
Continued
64
65
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
67
68
66
Date of birth
What is this child’s country of birth?
/ /
GenderMale
Female
69
Passport number
Country of issue
Has this child EVER travelled outside Australia, including short trips and holidays?
This question will help us to verify this child’s Australian residence.
Which of the following best describes your relationship to this child?
70 Please read this before you answer the question.
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.
Give details below
Parent
Grandparent
Step-parent
Foster carer
Other
71 Does this child currently live with you?
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
What is the percentage of your (or your partner’s) care of this child?
No
No
Yes
Yes
72
%
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?
Go to next question
Go to 77
Give details below
Go to next question
No
No
No
Yes
Yes
Yes
73
74
75
Year this child last entered Australia
No
Not applicable – never travelled to Australia
Yes
Go to next question
Go to next question
Give details below
SA468.1807 13 of 23
Child 2
Continued
Go to next questionNo
Yes Attach details of the other dependent children.
Go to next question
78 Do you provide care for another child under 18 years of age or full-time students under 22 years of age?
No
Yes
77 Do you receive Family Tax Benefit for this child?
Attach proof of birth or adoption (e.g. birth certificate or adoption papers) for this child if you have not previously provided it to us.
Go to next question
Go to next question
Does this child have any income?Go to next question
Amount
No
Yes
76
$ per week
SA468.1807 14 of 23
79
81
80
Please read this before answering the following questions.
Please read this before answering the following questions.
Do you (and your partner) have a tax file number(s)?
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(s) before?
Do you want tax taken out of your payment?
YouNo Please call us on 132 717.
Yes Your tax file number
Your partnerNo Please call us on 132 717.
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
82 Have you (and/or your partner) claimed or been paid any of the following payments in the last 14 days?
• ABSTUDY• Age Pension• Austudy• Carer Payment• Disability Support Pension • Family Tax Benefit• Newstart Allowance
• Partner Allowance• Parenting Payment• Sickness Allowance• Special Benefit• Widow Allowance/Pension• Wife Pension• Youth Allowance.
Go to next question
Do not answer questions 83 to 106.Go to 107
No
Yes
83 Do you (and/or your partner) own a home but live elsewhere?Go to next question
What is the reason you live away from the home you own?
No
Yes
Give details below
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
Other
SA468.1807 15 of 23
84 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 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 a retirement village
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 89
Go to 92
Give detailsbelow
Go to 99
Go to 107
Go to 86
Go to 97
Go to 97
85 Do you (and/or your partner) 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 86 to 106. Go to 107
Yes Go to 99
86 Are you (and/or your partner) the primary tenant(s)?
That is, your (and/or your partner’s) name is on the tenancy agreement (lease) with the public housing authority.
Go to next questionNo
Do not answer questions 87 to 106. Go to 107
Yes
88 Do you (and/or your partner) live with the primary tenant(s) AND your (and/or your partner’s) income has been taken into account by the public housing authority when calculating the rent?
No Do not answer questions 89 to 106. Go to 107
Yes Go to 98
87 Does the primary tenant pay rent at the market rate?Go to next question
Not sure Go to next question
Go to 98
No
Yes
89 What date did you (and/or your partner) move into the retirement village?
/ /
Go to next question
How much entry contribution did you pay?
No
Yes
Did you (and/or your partner) pay an entry contribution?90Your 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.
$
Attach documents to verify the details of your entry contribution (e.g. your contract).
Go to 98
Go to next question
How much was the gift?
Go to 94
How much was the loan?
No
No
Yes
Yes
Did you (and/or your partner) make a gift and/or loan in addition to the entry contribution?
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?
91
92
$
$
Go to 98
SA468.1807 16 of 23
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:
Give details below
Go to 107
Go to 107
Go to 97
Go to 97
Go to 107
Inherited the life interest
Have a formal agreement documenting your right to accommodation for lifeHave an informal arrangement with
children to live at their home and pay rent
Informal arrangement, no rent paid
Other
94 What date did you (and/or your partner) make this payment/transfer?
/ /
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?
$
$
96 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
97 What type of accommodation do you (and your partner) live in?
Go to 99
Give details below
Go to next question
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
Give details below
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).
No
Yes
Please read this before answering the following question.98
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
When did they move in?
/ /
2 Person’s name Age
Do they own the home?
Relationship to you
Their share of the rent/lodgings
No Yes$ per
When did they move in?
/ /
3 Person’s name Age
Do they own the home?
Relationship to you
Their share of the rent/lodgings
No Yes$ per
When did they move in?
/ /
4 Person’s name Age
Do they own the home?
Relationship to you
Their share of the rent/lodgings
No Yes$ per
If you share with more than four people, attach a separate sheet with details.
SA468.1807 17 of 23
99 Do you (and/or your partner) pay 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
100 Can you separate the amounts you (and/or your partner) pay for board and/or lodgings?
Total board and lodgings charged per day, week, fortnight, 4 weeks or calendar month
No
Yes
$ 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
$ per
$ per
Go to 102
101 How much do you (and/or your partner) pay per day, week, fortnight, 4 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
109
Do you (and your partner) live in a boarding house, hostel, private hotel, hospital or disability housing?
Are you (and/or your partner) receiving any other payment from the Department of Veterans’ Affairs?
Go to next question
Go to 105
Go to 111
No
No
Yes
Yes104 What is the total amount of rent charged for the property per day, week, fortnight, 4 weeks or calendar month?
106 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?
No Go to next question
Yes Attach a full copy of your signed lease or tenancy agreement.
105 Details of your landlord, authorised agent or person you (and/or your partner) pay rent to
Contact phone number
Full name
Address
Postcode
( )
Go to next question
Go to next question
No
No
Yes
Yes
Are you (and/or your partner) claiming Rent Assistance?
Are you (and/or your partner) receiving a New Zealand Government payment?
107
108
You will need to complete and attach an Income and Assets form (SA369) included in this pack. If you do not have this form, go to www.
humanservices.gov.au/rentassistance
Go to next question
Attach a letter or other document which gives the reference number and details of the payment.
Go to next question
$ per
SA468.1807 18 of 23
110 Which other payment do you (and/or your partner) receive from the Department of Veterans’ Affairs?
Tick ALL that apply
111 Do you (and/or your partner) receive payments from:• New Enterprise Incentive Scheme (NEIS) Allowance, or• Community Development Employment Projects (CDEP)
wages?
No Go to next question
Yes Attach a letter or other document(s) that shows the reference number and details for each payment (other than payments made by us).
Attach a letter or other document which gives the reference number and details of each payment.
Go to next question
Have you (or your partner) ever CLAIMED or are you (or your partner) ABLE TO CLAIM compensation, insurance and/or damages?
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
Please read this before answering the following questions.112
You will need to complete and attach a Compensation and damages form (Mod C). If you do not have this form, go to www.humanservices.gov.au/ centrelinkcompensationrecovery
Go to next questionNo
Yes
Are you (and/or your partner) RECEIVING or have you (and/or your partner) EVER BEEN PAID compensation, insurance and/or damages?
113
You will need to complete and attach a Compensation and damages form (Mod C). If you do not have this form, go to www.humanservices.gov.au/ centrelinkcompensationrecovery
Go to next question
114 Before you needed to make this claim, were you working as a wage or salary earner or about to start working as a wage or salary earner?
Go to 120No
Yes Go to next question
115 Is your employer keeping a job available for you?
Go to 120
Not sureGive details about your employer below
No
Yes
We may need to contact your employer to verify your employment details.
If you have more than one employer, attach a separate sheet with details.
Full name
Personnel number
Was this work
Australian Business Number (ABN)
Address
Postcode
Phone number
Fax number
( )
( )
Full-time Part-time Casual Seasonal
Disability Pension (War Pension)
Income Support Supplement
Service Pension
War Widow’s Pension
War Widower’s Pension
Other
Not sure
SA468.1807 19 of 23
Go to 118
Go to 120
How many hours are you working now?
No
No
No
Yes
Yes
Yes
Are you still working for this employer?
Is this a gradual return to work?
Are you being paid sick leave?
Tick ‘Yes’ if you expect to be paid sick leave.
116
117
118
119 Do you think you are about to lose your job because of your disability, illness or injury?
Go to 126
Go to next questionGo to next question
Go to next question
Give details belowGo to 126
No
NoNo
Yes
YesYes
Before you needed to make this claim, were you self-employed, working as a sub-contractor or a primary producer (e.g. a farmer, a market gardener)?
Do you operate through a company (as a principal or employee)?
120
121
122 Do you have a contract (written or oral contract) to provide goods or services?
Go to 126No
Yes Give details about your contract below
Go to next question
Written
Oral
What type of contract do you have?
Are you still doing this work?
123
124
Attach the written contract to provide goods and services.
How many hours are you working now?
Is this a gradual return to work?
hours per week
No Yes
Go to 126
125 Do you expect to return to this work?
Not sure
No
Yes
Full name
Australian Business Number (ABN)
Address
Postcode
Phone number
Fax number
( )
( )
hours per week
No
Yesint
int
SA468.1807 20 of 23
126 130
127
128
Before you needed to make this claim, were you studying (e.g. school, TAFE college, university)?
Before you needed to make this claim, were you doing something other than paid employment or study (e.g. voluntary work, unemployed, in receipt of another income support payment, financially dependent on someone else, caring for someone else, undertaking home duties, parenting, recovering from an illness or operation, undergoing rehabilitation)?
Were you studying:
Have you deferred your studies due to incapacity?
No
No
Full-time
No
Go to 130
Go to next question
Yes
Yes
Part-time
Yes
Give details below
Give details below
Phone number
How many hours are you studying now?
Name of school, TAFE college, other
Address
Postcode
( )
hours per week
129 Do you expect to return to your studies, after your incapacity ends?
Go to next question
Give details below
No
Not sure
Yes
Name of school, TAFE college, university, other
Address
Postcode
Phone number
( )
131 In the last 14 days have you (and/or your partner) received or claimed any of the following payments (not including Family Tax Benefit)?
• ABSTUDY• Age Pension• Austudy• Carer Payment• Disability Support Pension• Newstart Allowance• Partner Allowance
• Parenting Payment• Sickness Allowance• Special Benefit• Widow Allowance/Pension• Wife Pension• Youth Allowance.
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No
Yes
You (and your partner) will need to complete and attach an Income and Assets form (SA369) included in this pack. If you do not have this form, go to www.
humanservices.gov.au/sicknessallowance
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132 In the last 12 months, have you (or your partner), or do you (or your partner) expect to receive, any leave entitlement payments from an employer you have worked for?
No Go to next question
Yes Give details below
Include:• annual leave• maternity leave• long service leave• sick leave• leave loading.
Attach documents which confirm leave entitlement payments (e.g. letter from employer).
1 Type of leave entitlement
Amount you received or expect to receive before tax and other deductions
Number of working days covered by the payment
Date paid or date payable
Phone number
Name of employer
Job description
Address
Postcode
( )
/ /
$
Full name
Address
Postcode
Continued
If you have payments from more than two employers, attach a separate sheet with details.
133
134
Have you received a redundancy payment since 20 September 2006?
Do you, or does anyone else on your behalf, get a payment from a state and/or territory government?
This includes any organisation that gets a payment for you.
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Go to next question
Give details of the department or organisation below
No
No
Yes
Yes
Attach documents which confirm any redundancy payments (e.g. Employment Separation Certificate form (SU001), letter from employer). If you do not have this form, go to www. humanservices.gov.au/sicknessallowance
2 Type of leave entitlement
Amount you received or expect to receive before tax and other deductions
Number of working days covered by the payment
Date paid or date payable
Phone number
Name of employer
Job description
Address
Postcode
( )
/ /
$
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135 138
136
137
Do your disabilities, illnesses or injuries make it difficult for you to use public transport?
Which of the following forms, documents and other attachments are you (and/or your partner) providing with this form?If you are not sure, check the question to see if you should attach the documents.
Do your disabilities, illnesses or injuries make it difficult for you to care for yourself?
Do you use, or provide care for someone that is using, essential medical equipment or medically required heating/cooling in your current residence?
No
No
No
Go to next question
Go to next question
Go to next question
Yes
Yes
Yes
You may be eligible for Mobility Allowance which is paid to people with a disability who are unable to use public transport, without substantial assistance, permanently or for an extended period of time (1 year or more).You must be doing work, vocational training or voluntary work or participating in job search activities. For more information go to www.
humanservices.gov.au/mobilityallowance
If you have someone caring for you, they may be eligible for Carer Payment and/or Carer Allowance. For more information, call us on 132 717.
You may be eligible for Essential Medical Equipment Payment. For more information about how to claim, go to www.humanservices.gov.au/emep or call us on 132 468.
Where you are asked to supply documents, please attach original documents.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.
Identity documents For a list of acceptable documents refer to
Confirming your identity in the Notes Booklet
Authorising a person or organisation to enquire or act on your behalf form (SS313)
(If you answered Yes at question 5)
Dependent children proof of birth or adoption papers(If you answered No at question 77)
Details of other dependent children(if you answered Yes at question 78 on page 13)
Documents to verify details of an entry contribution(If you answered Yes at question 90)
Signed lease or tenancy agreement(If you answered Yes at question 106)
Income and Assets form (SA369) (if you answered Yes at question 107 or
if you answered No at question 132)
Letter or document which gives the reference number and details of each New Zealand payment
(If you answered Yes at question 108)
Letter or document which gives details of Department of Veterans’ Affairs payment(s) and
reference number(s)(if required for question 110)
Letter or document that shows the reference number and details of each NEIS Allowance or
CDEP wages payment(If you answered Yes at question 111)
Compensation and damages form (Mod C)(if you answered Yes at question 112 or 113)
The contract to provide goods and services(if required for question 123)
Documents which confirm your leave entitlements(If you answered Yes at question 132)
Documents which confirm any redundancy payment received OR Employment Separation
Certificate form (SU001)(if you answered Yes at question 133)
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SA468.1807 23 of 23
139 You need to read this
140
Obligations
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
Statement
I declare that:• the information I have provided in this form 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 relevant enquiries to make sure I receive the correct entitlement.
• 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
Your partner’s signature
Date
Date
/ /
/ /
1 Check that you have answered all the questions that you need to.
2 Attach all requested information and any additional required forms.
3 Check you have signed and dated this form.
You can return this form and any supporting documents:• online using your Centrelink online account.
For more information, go to www.
humanservices.gov.au/submitdocumentsonline
• by post to Department of Human ServicesDisability ServicesReply Paid 7806Canberra BC ACT 2610
• in person at one of our service centres, if you are unable to use your Centrelink online account.
Next steps
Returning your form
