South Australia bushfires – January 2015 claim form

Disaster Recovery Allowance
South Australia Bushfires
January 2015
1
Do you need an interpreter when dealing with us?
7
This includes an interpreter for people who have a hearing or
speech impairment.
To speak to us in languages other than English, call 131 202.
No
Go to 3
Yes
Go to next question
2
What is your preferred spoken language?
3
What is your preferred written language?
4
Do you have a Centrelink Reference Number?
Do any of the following apply to you?
Tick ALL that apply
Live in an affected area
Suburb
Work in the affected area
Suburb
Derive income from the
affected area
Suburb
None of the above
8
No
Go to next question
Have you lost or suffered a reduction in your income as a direct
result of the disaster?
Yes
Your Centrelink Reference Number (if known)
No
Yes
5
Are you receiving an income support payment or pension
(e.g. Age Pension, Newstart Allowance, Service Pension from the
Department of Veterans’ Affairs or Exceptional Circumstances
Income Relief Payment)?
9
Go to next question
No
You may not be eligible for this assistance.
Please call us on 180 22 66.
Yes
6
You may not be eligible
for this assistance.
Please call us on
180 22 66.
You may not be eligible for this assistance.
Please call us on 180 22 66.
Go to next question
Are you 22 years of age or older?
No
Go to next question
Yes
Go to 14
10 Please read this before answering the following questions.
Questions 10–13 are to be completed ONLY if you are under
22 years of age.
Do any of the following apply to you?
Are you a parent or have a dependent child in your care?
Tick the first option
that applies to you
An Australian citizen
Go to next question
A permanent visa holder
Go to next question
A New Zealand passport holder
Go to next question
Holder of an
eligible temporary visa
Go to next question
No
Go to next question
Yes
Go to 14
Refer to the factsheet
for a list of eligible
temporary visa classes.
None of the above
You may not be
eligible for this
assistance.
Please call us on
180 22 66.
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11 What is your estimated income for the current financial year?
18 What was your place of residence at the time of the disaster?
$
12 Are you wholly or substantially dependent on another person?
Refer to the factsheet for an explanation of ‘wholly or
substantially dependent’.
Postcode
19 What is the address of your current residence?
(if different to above)
No
Yes
13 Are you currently living with your parent(s) or guardian(s)?
Postcode
No
Is this a temporary residence?
Yes
14 Your name
Mr
No
Yes
20 Postal address (if different to above)
Mrs
Miss
Ms
Other
Family name
Postcode
First given name
21 IMPORTANT
Second given name
This payment can be paid for a maximum period of 13 weeks
dependent on your circumstances. Before the end of the
13 weeks we will contact you to advise of the required steps
that must be taken if you require further assistance. Please
ensure your contact details are always up to date.
15 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)?
No
Go to next question
Yes
Give details below
How can we contact you?
Phone number (
)
To help us serve you better, please provide your mobile number
Other name
Mobile phone number
Note: This mobile number will automatically be subscribed
to our electronic messaging service. We may use this mobile
number to contact you. For Terms and Conditions, go to our
website humanservices.gov.au/em
Type of name (e.g. name at birth)
www.
If you have more than 1 other name, attach a separate sheet
with details.
22 Were you in Australia when the disaster occurred?
No
Go to next question
Yes
Go to 24
16 Your sex
23 When did you return to Australia after the disaster?
Male
Female
/
17 Your date of birth
/
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24 Please read this before answering the following questions.
31 Are you subject to an Assurance of Support agreement?
‘Permanently’ means you normally live in Australia on a
long-term basis. Holidays or short trips outside Australia
would not affect this.
No
Go to next question
Yes
What is the name of your Assurer?
Are you living in Australia permanently?
No
Yes
32 Except for short trips or holidays, have you EVER lived outside
Australia?
No
Go to next question
25 Have you lived or travelled outside Australia since
1 September 1994, including short trips and holidays?
Yes
The answer to this question may enable Human Services to
access electronic records held by Australia’s immigration
department and help verify your Australian residence.
No
Go to next question
Yes
Give details below
List ALL countries, INCLUDING AUSTRALIA, you have
lived in SINCE BIRTH.
Include the period(s) you have lived in Australia.
If you were born outside Australia, include the country
where you were born.
Do NOT include short trips or holidays.
1 Country of residence
Passport number
From
Country of issue
/
/
To
/
/
To
/
/
2 Country of residence
26 Are you an Australian citizen who was born in Australia?
No
From
You will need to provide proof of your
Australian residence status (e.g. citizenship
papers, passport or other documentation).
Go to next question
/
If you require more space, attach a separate sheet with details.
33 Do you have a partner?
Go to 32
Yes
/
27 What is your country of birth?
No
Go to 42
Yes
Go to next question
34 Does your partner have a Centrelink Reference Number?
28 What is your country of citizenship?
Australia
No
Go to next question
Yes
Your partner’s Centrelink Reference Number (if known)
Date you became an Australian citizen
/
Other
/
Go to 31
35 Your partner’s name
Country of citizenship
Mr
Mrs
Miss
Family name
29 What is your current type of visa?
New Zealand passport
(special category visa)
Go to 32
First given name
Permanent
Go to next question
Temporary
Go to next question
Unknown (e.g. arrived
on parent’s passport)
Second given name
Go to 31
30 Your current visa details
Visa sub class
Date visa granted
/
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Ms
Other
36 Has your partner ever used or been known by any other name
43 Give details below of your youngest dependent child
(e.g. name at birth, maiden name, previous married name,
Aboriginal or tribal name, alias, adoptive name, foster name)?
No
Go to next question
Yes
Give details below
Child’s family name
Child’s given names
Other name
Other name this child has been known by
Child’s date of birth
Type of name (e.g. name at birth)
/
Child’s sex
/
Male
Female
Are you the principal carer of this child?
If your partner has more than 1 other name, attach a separate
sheet with details.
No
Yes
Is there a shared care arrangement in relation to this child?
37 Your partner’s sex
No
Yes
What is your percentage of shared care?
Male
%
Female
Do you receive Family Tax Benefit for this child?
No
Yes
38 Your partner’s date of birth
/
/
44 Provide details of your usual work (e.g. employment,
self-employment, sub-contracting, farming).
39 Does your partner live at the same ‘residential address’ as you?
No
Go to next question
Yes
Go to 41
Employer’s name, business name or farm name
Australian Business Number (ABN)
40 Your partner’s residential address
Address
Postcode
Postcode
41 Do you give permission for your partner to discuss details about
Phone number
your claim?
(
No
)
What industry are you employed in?
For example:
a banana industry should write: Agriculture – banana industry
a clothes shop assistant should write: Retail – clothes.
Yes
42 Do you have dependent children under 16 years of age in your
care?
Note: There are no additional payments for dependent
children. If you currently receive Family Tax Benefit you may
need to revise your income estimate.
No
Go to 44
Yes
Go to next question
Is this work
Full-time
Other
Part-time
Seasonal
Casual
Give details
Was your income from this employer impacted as a result of
the disaster?
No
Yes
If you have more than one employer, attach a separate sheet
with details.
You must answer questions 44 to 53 for each employer.
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45 Are you self-employed?
52 Is this paid leave?
Go to next question
No
Yes
No
Yes
The income you receive from self-employment must
be included at question 65 and question 66.
53 Have you returned to work after the disaster?
46 What date did you stop working or first incur a reduction in your
income as a result of the disaster?
/
No
Go to next question
Yes
Date you returned to work after the disaster
/
/
47 Which one of the following reasons best describes why you have
suffered a loss of income?
/
54 Do you have an income protection policy?
Workplace damaged or destroyed
I am unable to get to my usual workplace
No
Go to 58
Yes
Name of insurance company
Cancelled bookings/orders
Cancellation of planned tourism events
55 Have you lodged a claim or intend to lodge a claim for the loss
Loss and/or damage to stock
of income?
No
Go to next question
Injury suffered
Go to 57
Yes
Loss and/or damage of machinery/tools
Loss of necessary utilities
56 Explain why you have not lodged a claim
Lack of staff/workers/contractors
Unable to import/export products
Other
Go to 58
57 What was the outcome of the claim?
Pending decision
48 Explain why you stopped work in further detail
Rejected
Note: If you did not stop working as a result of the disaster
you may not be eligible for this assistance.
To be lodged in future
Granted
Give details below
Has a waiting period been applied?
No
Yes
Waiting period end date
/
/
Have payments commenced?
No
49 Are you on planned leave from your workplace?
No
Go to 53
Yes
Go to next question
Yes
Attach a copy of the most recent letter or
statement from the insurance policy
provider showing payment details.
Any income you receive from this insurance
policy must be included at question 69.
50 What type of leave?
For example: annual leave, sick leave, maternity.
58 Do you have an interest in any real estate in and/or outside
51 Start date of leave period
/
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Australia (other than your principal place of residence)?
No
Go to 60
End date of leave period
/
Yes
/
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Go to next question
59 Do you receive an income from the properties (i.e. rental/lease
62 Do you have any managed investments in and/or outside
income)?
Go to next question
No
Yes
Australia?
Include:
• investment trusts
• personal investment plans
• life insurance bonds
• friendly society bonds.
Do NOT include:
• conventional life insurance policies
• funeral bonds, superannuation or rollover investments.
APIR code – is commonly used by fund managers to identify
individual financial products.
Attach a copy of your tax return for the
previous year when lodging this claim.
The income you receive from rental properties must
be included at question 65 and question 69.
60 Do you own any shares, options, rights, convertible notes or other
securities LISTED on an Australian Securities 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.
No
No
Go to next question
Yes
Give details below
Go to next question
Yes
Attach a document which gives details
(e.g. certificate with number of units or
account balance) for each investment.
Attach the latest statement for each
investment.
The income you receive from these investments
must be included at question 65 and question 69.
The income you receive from these investments
must be included at question 65 and question 69.
1 Name of company
1 Name of company
Number of shares or
other securities
Security code (if known)
Name of product
(e.g. investment trust)
Country if not Australia
Your share
Number of units
Type of product/option
(e.g. balanced, growth)
APIR code (if known)
%
Current market value
If you have more than 1 investment, attach a separate sheet
with details.
$
Your share
61 Do you own any shares, options or rights in PUBLIC companies
NOT Listed on a stock exchange?
Go to next question
Yes
Attach the latest statement for each
investment.
The income you receive from these investments
must be included at question 65 and question 69.
1 Name of company
Type of shares, options or rights
Number of shares, options or rights
Current market value
$
Your share
%
If you have more than 1 investment, attach a separate sheet
with details.
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%
If you have more than 1 managed investment, attach a
separate sheet with details.
Do NOT include managed investments.
No
Currency if not AUD
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63 Please read this before answering the following question.
64 Do you have any money invested or do you receive income from
any other investments or sources, not declared elsewhere on this
form?
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 superannuation fund
• a Self Managed Superannuation Fund (SMSF)
• a Small APRA Fund (SAF)
• an employer subject to Australian prudential regulations.
Types of income streams include:
• Allocated Pension (also known as Account Based 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 NOT include
• an account used exclusively for funding from the National
Disability Insurance Scheme
• bank accounts, or
• private companies.
Go to next question
Yes
Give details below
Go to next question
Yes
Give details below
You will need to provide proof of your income
from other investments and sources.
The income you receive from these investments or
sources must be included at question 65 and
question 69.
Do you receive income from any income stream products?
No
No
1 Type of investment/income
Name of organisation/company
You will need to obtain a schedule from your
product provider for each income stream
product.
Currency if not AUD
The income you receive from income stream
products must be included at question 65 and
question 69.
Your share
%
If you have more than 1 other investment or source of income,
attach a separate sheet with details.
1 Name of product provider/SMSF/SAF
65 What was your gross income for the 8 weeks immediately before
Type of income stream
the disaster?
Product reference number
Gross income is the amount of income you earn before any
deductions are taken out (e.g. tax).
Include income from all sources, this includes income from
employment, income protection policies, shares, investments,
real estate income, superannuation, self-employment, holiday
pay, commission work etc.
Your share
%
If you have more than 1 income stream, attach a separate
sheet with details.
Attach verification documents to confirm your income
(e.g. payslips, tax returns, BAS statements or a letter
from your employer).
Source of income
Amount
$
$
$
$
$
$
$
Total for 8 week period $
If you have more than 7 sources of income, attach a separate
sheet with details.
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66 If the disaster had not occurred, would your income have
70 Do you have any accounts in banks, building societies, credit
continued at the same fortnightly amount in the 13 weeks
following your loss of income as it was before the disaster?
No
Go to next question
Yes
Go to 69
unions or church and charitable development funds?
Do NOT include
• an account used exclusively for funding from the National
Disability Insurance Scheme
• bank accounts held in trust, or
• private companies.
67 Did you expect your income to:
Tick ONE only
Decrease
Increase
No
Go to next question
Yes
Give details below
1 Name of bank, building society or credit union
68 How much did you expect to earn each fortnight on average for
the 13 weeks after the disaster?
$
Type of account
per fortnight
Branch number (BSB)
You will only need to provide proof of the expected
increase in income (e.g. contract documents).
Account number (this may not be your card number)
69 In the 14 days following your loss of income, did you receive,
or are you entitled to receive, any income from any source?
Balance
Gross income is the amount of income you earn before any
deductions are taken out (e.g. tax).
Include income from employment, income protection policies,
shares, investments, real estate income, superannuation,
self-employment, holiday pay, commission work etc.
No
Go to next question
Yes
Give details below
Your share
$
%
2 Name of bank, building society or credit union
Type of account
You will need to provide proof of your income.
Source of income
Branch number (BSB)
Amount
Account number (this may not be your card number)
$
$
Balance
$
Your share
$
%
$
If you have more than 2 accounts, attach a separate sheet with
details.
$
Total
$
If you have more than 5 sources of income, attach a separate
sheet with details.
71 Do you have any cash?
No
Go to next question
Yes
How much cash do you have?
$
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72 Please read this before answering the following questions.
76 Would you like a Centrelink social worker to contact you?
You are not breaking the law if you do not give us your tax file
number, but if you do not provide it to us, 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
Go to next question
Yes
What number would you like to be contacted on?
(
)
77 Checklist
Have you given us your tax file number before?
No
Go to next question
Not sure
Go to next question
Please tick what information has been provided with the claim.
If verification documentation is not provided with this claim it
will need to be provided within 14 days.
Go to 74
Yes
All questions on this claim have been completed
73 Do you have a tax file number?
No
Please call us on 180 22 66.
Yes
Your tax file number
Proof of identity that add up to the value of 50 points
(refer to the factsheet for acceptable forms and
point value of documents)
Passport or visa details (if not an Australian citizen)
(if you answered No at question 26)
Copy of your tax return for the previous year
(if you answered Yes at question 59)
74 Please read this before answering the following question.
The latest statement or document for each investment
(if you answered Yes at question 60, 61 or 62)
Disaster Recovery Allowance is a taxable payment. 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.
A schedule from your product provider
for each income stream
(if you answered Yes at question 63)
Proof of income from investments or other sources
(if you answered Yes at question 64)
Proof of income before the disaster
(if required at question 65)
Proof of expected increased income
(if required at question 68)
Do you want tax taken out of your payment?
No
Go to next question
Yes
Enter the amount OR percentage of tax you want taken
out from each payment.
Amount
Percentage (%)
(must be in whole dollars)
of taxable payment
$
.00 per payment OR
Proof of income for the 14 days
following your loss of income
(if you answered Yes at question 69)
% per payment
75 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.
I do not have a bank, building society
or credit union account
We will contact you
to discuss
Go to next question
The account nominated below
Name of bank, building
society or credit union
Branch where your
account is held
Branch number (BSB)
Account number
(this may not be your
card number)
Account held in the name(s) of
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78
IMPORTANT INFORMATION
Office Use only
Privacy and your personal information
Your personal information is protected by law, including the
Privacy Act 1988, and is collected by the Australian
Government Department of Human Services for the
assessment and administration of payments and services.
This information is required to process your application or
claim.
CSO Logon ID
POI type
Serial number
Human Services may disclose your information to
Commonwealth departments, other persons, bodies or
agencies ONLY where you have provided consent or it is
required or authorised by law.
Issue date
Human Services may disclose limited personal information
about you to individuals when your circumstances affect their
entitlement to payments and services. Your information may
be disclosed to the Attorney-General’s Department, the
Department of Immigration and Border Protection and their
service providers, or as authorised or required by law. Relevant
information may be given to Australian and State Government
Departments and Agencies who are involved in the joint
administration of this disaster.
Your information may be used by the department or given to
other parties for the purposes of research, investigation or
where you have agreed or it is required or authorised by law.
You can get more information including our privacy policy at
humanservices.gov.au/privacy or by requesting a copy from
the department.
/
Expiry date
/
State of issue
/
/
Country of issue
POI type
Serial number
Issue date
/
www.
Expiry date
/
State of issue
/
/
Country of issue
79 Statement
I declare that:
• the information provided in this form is complete and correct.
• I have read the privacy notice above.
I understand that:
• 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.
• the Australian Government Department of Human Services
may request evidence to support any claims made on this
form.
• I must tell the Australian Government Department of Human
Services of any changes to this information within 14 days.
• any overpayment will be recovered.
POI type
Serial number
Issue date
/
Expiry date
/
State of issue
/
/
Country of issue
POI type
Your signature
Serial number
Issue date
Date
/
/
/
State of issue
Expiry date
/
/
Country of issue
Original document sighted and returned
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