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Claim for an annual lump sum

payment of Family Tax Benet


Date stamp
Customer details
Customer name
Centrelink
Reference Number
Once date stamped by us, this receipt is proof that your claim for Family Tax
Benet has been lodged.
FA048.1407
FA048.1407
O F F I C E U S E O N L Y / C U S T O M E R R E C E I P T
A payment to help families with the cost of
raising children for the 20132014 nancial year
Filling in this form Please use black or blue pen.
Print in BLOCK LETTERS.
Mark boxes like this with a or .
Where you see a box like this Go to 5 go to the question number shown. You do not
need to answer the questions in between.
Use this form if you wish to claim Family Tax Benefit as an annual lump sum payment.
You should have received the booklet Information Booklet about your claim for Family
Assistance (Ci011) with this form. In this claim, this booklet will be referred to as the Information
Booklet. If you do not have this booklet, go online www.humanservices.gov.au/forms
When to use this form
For more information Go online www.humanservices.gov.au/families or call us on 136 150 or visit one of our Service
Centres.
To speak to us in languages other than English, call 131 202.
Note: Call charges apply calls from mobile phones may be charged at a higher rate.
If you have a hearing or
speech impairment
TTY service Freecall 1800 810 586. A TTY phone is required to use this service.
This form tells you which other documents you need to provide to support your claim.
Depending on your circumstances you may have to fill in other forms.
What else you will need to
provide
If you need an interpreter or translation of any documents for our business, we can arrange
this for you free of charge.
Interpreters and
translations
You can claim an annual lump sum payment of Family Tax Benefit online www.
humanservices.gov.au/centrelinkonline
You can access your Centrelink, Medicare and Child Support Online Services through myGov.
myGov is a fast, simple way to access a range of government services online with one username,
one password, all from one secure location. To create a myGov account go to www.my.gov.au
Online Services
Returning your form To claim for a lump sum payment of Family Tax Benefit for the 20132014 financial year, you (and
your partner) must complete and lodge this form by 30 June 2015. If there are special circumstances
that prevent you from lodging your claim, please call us on 136 150 to discuss.
Check that you (and your partner) have answered all the questions you need to answer, and that
you (and your partner) have signed and dated this form.
If you return required documents (and your claim form):
online you can submit your documents online if you are registered for Online Services.
by post we will sight and record your documents, which may include copying, and return the
originals to you by registered post.
in person we will sight and record your documents, which may include copying, and return
the originals to you.
If you do not wish to claim online, please complete this form and return it (with any requested
documents) as soon as possible by post to:
Department of Human Services
Families
Reply paid 7802
CANBERRA BC ACT 2610
Alternatively, you can return your form to one of our Service Centres. For more information on how
to access Online Services or how to lodge documents online, go to www.
humanservices.gov.au/submitdocumentsonline
What is your preferred written language?
Go to 4
What is your preferred spoken language?
No
Yes
Do you need an interpreter when dealing with us?
This includes an interpreter for people who have a hearing or
speech impairment.
2
Personal details
2 of 58
Go to next question
Are you claiming online? 1
No
Yes Do not complete this form. Go online www.
humanservices.gov.au/centrelinkonline
Go to next question
3
4 What is your partners preferred written language?
Go to 4
What is your partners preferred spoken language?
No
Yes
Does your partner need an interpreter when dealing with us?
This includes an interpreter for people who have a hearing or
speech impairment.
2
Go to next question
3
4
FA048.1407
You Your partner (if you have one)
CLK0FA048 1407
FA048.1407
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Other
Family name
First given name
Second given name
Ms Miss Mrs Mr
Your name 7
Go to next question
Other name
Type of name (e.g. name at birth)
Give details below
1
No
Yes
Other name
Type of name (e.g. maiden name)
2
If you have more than 2 other names, attach a separate sheet
with details.
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)?
8
You Your partner on 30 June 2014
If your partner has more than 2 other names, attach a
separate sheet with details.
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)?
Your partners name
Other
Family name
First given name
Second given name
Ms Miss Mrs Mr
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 our websitewww.
humanservices.gov.au/nominees
Go to next question
Do you want to authorise another person or organisation to make
enquiries, get Centrelink payments and/or act on your behalf?
5
No
Yes
Did you have a partner on 30 June 2014? 6
No
Yes
Go to next question
Other name
Type of name (e.g. name at birth)
Give details below
1
No
Yes
Other name
Type of name (e.g. maiden name)
2
When completing the partners details in this
form we are referring to the partner you had
on 30 June 2014.
7
8
FA048.1407
Male
Female
/ /
Your sex 9
Your date of birth 10
Your Centrelink Reference Number (if known) 11
Male
Female
/ /
Your partners sex
Your partners date of birth
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Postcode
Your permanent address 12
Your postal address (if different to above) 13
Your contact details 14
Home phone number
Is this a silent number? No Yes
Mobile phone number
Work phone number
Your partners contact details (if different)
You Your partner on 30 June 2014
Postcode
( )
( )
Home phone number
Is this a silent number? No Yes
Mobile phone number
Work phone number
( )
( )
Your partners Centrelink Reference Number (if known)
Postcode
Your partners permanent address (if different to your address)
Your partners postal address (if different to above)
Postcode
9
10
11
12
13
14
Email address
@
Email address
@
Is this a silent number? No Yes Is this a silent number? No Yes
17 15
16
Have you (and your partner) given us your tax file number(s)
before?
You are not breaking the law if you do not give us your (and
your partners) tax file number(s), but if you do not provide
them to us you will not be paid.
In giving us your (and your partners) tax file number in relation
to this claim you authorise us to use your (and your partners)
tax file number for other family assistance payments and
services in future where necessary.
Please read this before answering the following questions
Go to 17
Go to next question Not sure
Yes
Go to next question No
5 of 58
If you had a partner on 30 June 2014, were you in a relationship
with them for only part of the 20132014 financial year?
No
Yes
Go to next question
From
/ /
To
/ /
Give details below
/ / / /
18
What was your relationship status on 30 June 2014?
Please read this before answering the following question
We recognise both opposite-sex and same-sex relationships.
This includes relationships registered under state or territory
law.
Select ONE option below that best describes your relationship
status on 30 June 2014.
Married Date of marriage
/ /
Partnered
(living together in an opposite-
sex or same-sex relationship,
including de facto)
Date you started living with
a partner
/ /
Divorced Date of divorce
/ /
Widowed
(previously partnered with an
opposite-sex or same-sex partner,
including in a marriage, registered
or de facto relationship)
Date of partners death
/ /
Separated
(previously lived with an opposite-
sex or same-sex partner, including
in a marriage, registered or
de facto relationship)
Date of last separation
/ /
Never married or lived
with a partner
If none of the above describes your relationship status, please
call us on 136 150.
Registered relationship
(opposite-sex or same-sex
relationship registered under state
or territory laws)
Date registered
/ /
Go to 18
Go to 18
Go to 18
Go to 20
Go to 20
Go to 20
Go to 20
Your tax file number
Your partners tax file number
Do you (and your partner) have a tax file number?
Please call us on 136 150. No
Yes
Please call us on 136 150. No
Yes
You
Your partner
Do you give permission for your partner to speak with us on
your behalf?
You can change this authority at any time.
19
No
Yes
FA048.1407
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20
Are you (and/or your partner) 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.
Questions 20 and 21 are optional and will not affect your
payment. If you do answer, the information will help us 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 (and/or your partner) of Australian South Sea Islander
origin?
21
No
Yes Aboriginal Australian
Yes Torres Strait Islander
Australian
No
Yes Aboriginal Australian
Yes Torres Strait Islander
Australian
You Your partner
No
Yes
No
Yes
You Your partner
22
No
Yes
Are you an Australian citizen who was born in Australia? 24
No
Yes
You will need to provide proof of your Australian
residence status (e.g. citizenship papers,
passport or other documentation).
Go to next question
When did you most recently start living in Australia? 26
/ /
Are you living in Australia permanently?
Permanently means you normally live in Australia on a long-
term basis. Holidays or short trips outside Australia would not
affect this.
Please read this before answering the following question
Go to next question
Give details below
Have you lived or travelled outside Australia since
1 September 1994, including short trips and holidays?
23
No
Yes
Passport number
Country of issue
What is your country of birth? 25
What is your country of citizenship? 27
Go to 31
/ /
Other Country of citizenship
Go to 31
Residence details
What type of visa did you arrive on?
Permanent
Temporary
Unknown (e.g. arrived
on parents passport)
Your visa details on arrival
Visa sub class Date visa granted
/ /
28
29
Go to next question
Go to next question
Go to 30
The answer to this question may enable Human Services to
access electronic records held by Australias immigration
department and help verify your Australian residence.
New Zealand passport
(Special Category Visa)
Go to 30
Australia Date granted
Please read this before answering the following questions
FA048.1407
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In the last 3 years, up until 30 June 2014, have you lived outside
Australia for any period?
31
If you require more space, attach a separate sheet with details.
Where do you want your lump sum payment made?
Name of bank, building
society or credit union
Branch where your
account is held
Account number
(this may not be your
card number)
Account held in the name(s) of
Branch number (BSB)
32
Account details
A blended family is a family with 2 or more children and:
at least one of those children is a child of one member of
the couple from a previous relationship, and
at least one of the other children is a child of this
relationship or the child of the other member of the couple
from a previous relationship
both members of the couple must have a Family Tax Benefit
child in their care for at least 35 per cent of the time.
For more information, see Blended family in the Information
Booklet.
Please read this before answering the following question 33
Are you in a blended family?
No
Go to next question
Go to 36
Yes
Go to next question
Give details of the date you left Australia and started
living in another country and the date you returned to
Australia to live.
Only include an absence if it was permanent.
Do NOT include holidays or short trips.
No
Yes
Has your visa changed since you arrived in Australia?
Go to next question No
Yes
Visa sub class Date visa granted
/ /
Current visa details
30
The bank, building society or credit union account must be
in your name. A joint account is acceptable. It cannot be in
a childs name unless you are the signatory or trustee.
If you are currently receiving family assistance from us and
you provide different bank account details then all Family
Tax Benefit payments and Child Care payments will be
directed to this new account.
Note: Payments cannot be made into an account used
exclusively for funding from the National Disability Insurance
Scheme.
Blended family details
Departure date Return date
If you are a blended family, you and your partner can choose
to share your combined Family Tax Benefit amount. You can
decide between you and your partner what percentage of your
combined amount you will each receive.
Please read this before answering the following question 34
Do you and your partner want to be paid your Family Tax Benefit
separately?
No
Go to next question
Go to 36
Yes
Each member of a blended family must claim Family Tax
Benefit the same way, as either fortnightly payments or a lump
sum claim through us.
Your partner will need to complete a separate claim before you
can start being paid your percentage of Family Tax Benefit.
Only provide details of the children you are claiming Family Tax
Benefit for.
Please read this before answering the following question 35
What percentage of your familys entitlement to Family Tax
Benefit do you want to claim?
%
/ / / /
/ / / /
FA048.1407
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Were your accommodation details different in the 20132014
financial year to those you have provided, or will provide on your
fortnightly payments claim form?
40
No
Yes
Did you (and/or your partner) own a home but live elsewhere? 42
Do not answer questions 41 to 64.
Go to 65
Go to next question
Which of the following best describes where you lived? 43
In accommodation which you (and/or your
partner) had the right to use for life
Other (e.g. this could be a place where you
(and/or your partner) did not have a fixed
address) Give details
below
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)
paid private rent (this includes site or
mooring fees)
In a boarding house/hostel/private hotel
In a home which was owned by a private
company or a private trust that you had an
interest in Go to 67
Go to 44
Go to 48
Go to 45
Go to 53
Go to 55
Go to 53
In a home you (and/or your partner) owned
or you owned jointly with another person,
this can include:
paying it off (mortgage)
a caravan, transportable home or boat
In accommodation where you did not pay
rent
Go to 67
Did you pay site, ground or mooring fees for the home you owned
(this could be for a caravan, transportable home or boat)?
44
Go to 53
No
Yes
Do not answer questions 45 to 66.
Go to 67
If you changed accommodation several times during the
20132014 nancial year, attach a separate sheet with your
accommodation details (in questions 42 to 63) for each period.
Please read this before answering the following question 41
No
Yes
Not sure Go to next question
You will need to complete a claim for family
assistance by going online www.
humanservices.gov.au/centrelinkonline or
complete a Claim for Paid Parental Leave
and Family Assistance form (FA100).
Do you have an eligible child, for Family Tax Benefit purposes, in
your care NOW?
Are you currently receiving fortnightly payments of Family Tax
Benefit?
Do you want to claim fortnightly payments of Family Tax Benefit?
Rent Assistance is not payable
Do not answer questions 39 to 66.
Go to 67
Rent assistance details
Have you given details about your accommodation to us before? 39
36
37
38
No
Go to next question
Go to 39
Yes
No
Yes
No
Yes
No
Go to next question
Go to 41
Yes
Go to 39
Go to next question
Go to next question
Go to next question
What is the reason you live away from the home you
own?
Travelling away from your home
Being cared for away from your home
Caring for someone away from your home
Living away from your home
Other Give details
below
FA048.1407
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That is, your (and/or your partners) name was on the rental
contract (lease) with the public housing authority.
Were you (and/or your partner) the primary tenant? 45
Do not answer questions 46 to 66.
Go to 67
No
Yes
Go to next question
Did the primary tenant pay rent at the market rate? 46
No
Yes
Go to next question
Go to 54
Not sure Go to next question
Did you (and/or your partner) live with the primary tenant AND
your (and/or your partners) income was taken into account by
the public housing authority when calculating the rent?
47
No
Yes
Do not answer questions 48 to 66.
Go to 67
Go to 54
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?
48
No
Yes
Go to next question
Go to 50
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:
49
Inherited the life interest
Had a formal agreement documenting your
right to accommodation for life
Had an informal arrangement with children
to live at their home and pay rent
Go to 67
Go to 67
Go to 53
Other Give details
below
Go to 53
Had an informal arrangement, no rent paid Go to 67
What date did you (and/or your partner) make this
payment/transfer?
50
/ /
Details of the payment/transfer 51
How much did you (and/or your partner) pay?
$
AND/OR
What assets were transferred?
Market value of assets transferred?
$
Details of the person or organisation that the payment/transfer
was made to
52
Full name (of the person or organisation)
Address
Postcode
What type of accommodation did you (and your partner) live in? 53
Private house or townhouse/unit/flat
Defence housing
Caravan/cabin/mobile home
Boat
Community housing
Boarding house/hostel/private hotel
Other Give details below
Go to next question
Go to 55
Go to next question
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54
Did 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, fishermen,
members of the armed forces).
No
Yes
Go to 55
Give details below
If you shared with more than 4 people, attach a separate sheet
with details.
Age
Persons name
1
Relationship to you
No Yes
Do they own the home?
Period this person shared
From
Their share of the rent/lodgings
/ /
$
55
57
56
Did you (and/or your partner) pay board and/or lodgings?
No
Yes
Go to 57
Go to next question
How much did 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 paid for the property minus any
subsidy/rebate or contribution from another person or
organisation.
Can you separate the amounts you (and/or your partner) paid for
board and/or lodgings?
No
Yes
Board means you (and/or your partner) were provided with
some regular meals.
Lodgings means no meals were provided to you (and/or your
partner).
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
Total board and lodgings charged per day,
week, fortnight, 4 weeks or calendar month
Go to 58
To
/ /
Continued
$ per
$ per
$ per
$ per
54 Please read this before answering the following question
per
Age
Persons name
2
Relationship to you
No Yes
Do they own the home?
Period this person shared
From
Their share of the rent/lodgings
/ /
$
To
/ /
per
Age
Persons name
3
Relationship to you
No Yes
Do they own the home?
Period this person shared
From
Their share of the rent/lodgings
/ /
$
To
/ /
per
Age
Persons name
4
Relationship to you
No Yes
Do they own the home?
Period this person shared
From
Their share of the rent/lodgings
/ /
$
To
/ /
per
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59
60
58
Did you (and/or your partner) live in a boarding house, hostel,
private hotel, hospital or disability housing?
No
Yes
Go to next question
Go to 61
What was the total amount of rent charged for the property per
day, week, fortnight, 4 weeks or calendar month?
When did you (and/or your partner) start paying this amount?
61
62
Details of your landlord, authorised agent or person you (and/or
your partner) paid rent to
Full name
Address
Postcode
Did you (and/or your partner) have a current lease or tenancy
agreement which shows the amount of rent, fees, lodgings or
board and lodgings you (and/or your partner) paid?
No
Yes
Go to next question
Attach a full copy of your current lease or
tenancy agreement which must include the
terms and conditions.
If you had a partner in the 20132014 financial year, did you live
with them for the entire year?
65
Did not have a partner Go to 67
No
Yes Go to 67
Go to next question
Was this separation: 66
for medical reasons? No
Yes
temporary? No
Yes
because your partner
was in prison?
No
Yes
This question is to determine if you are eligible for a higher
amount of Rent Assistance.
Contact phone number
( )
63 During what period did you live in this accommodation?
/ /
To From
64 Did your accommodation details change in the 20132014
financial year?
No
Yes
Go to next question
You will need to answer questions 42 to 63 for each
type of accommodation you lived in during the
20132014 financial year, attach a separate sheet
with details.
What were the periods of the separation?
/ /
/ /
/ /
To From
/ /
/ / / /
/ / / /
$ per
FA048.1407
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Please read this before answering the following questions
Give the following details for each child who was in your care during the 20132014 financial year (1 July 201330 June 2014).
For more information, see Eligible child in the Information Booklet.
You will need to provide proof of birth to claim for any children where proof of birth has not been provided to us for family assistance
payments.
If you had more than 4 children during the 20132014 financial year, photocopy and attach pages 12 to 20 for each additional child
before completing the details for child 1.
67
Child details
Child 1
Childs first given name
Childs family name 68
70 Childs sex
Male
Female
Childs second given name
Childs date of birth 71
/ /
Has this child been known by any other names?
No
Yes List the other names
69
Go to next question
What is this childs country of birth? 72
Has this child EVER lived or travelled outside Australia, including
short trips and holidays?
73
The answer to this question may enable Human Services to
access electronic records held by Australias immigration
department and help verify this childs Australian residence.
No
Yes Give details below
Go to next question
Passport number
Country of issue
Was this child part of a multiple birth, multiple entrustment to
care or multiple adoption?
74
No
Yes
75 The term parent refers to a natural parent or a person who
is legally responsible for a child born through an assisted
conception procedure.
Your partners (if you have one) relationship to this child
Give details below
Partner of birth mother
Biological father
Partner of biological father
Grandparent
Other
Birth mother
Your relationship to this child 76
Adoptive parent
Foster parent (formal)
Foster parent (informal)
Give details below
Partner of birth mother
Biological father
Partner of biological father
Grandparent
Other
Birth mother
Adoptive parent
Foster parent (formal)
Foster parent (informal)
Go to next question
Go to 79
Go to 82
Go to 78
Go to 78
Go to 80
Go to 80
Go to 80
Go to 80
77 Have you given birth to any other children (excluding stillborn
children) before this child?
No
Yes Go to 84
Go to 84
FA048.1407
No
Yes
Was this child under 16 years of age on 30 June 2014?
Go to next question
Go to 93
88
Was this child studying during the 20132014 financial year? 89
No
Yes Highest level of study during 20132014
Go to 92
No
Yes
Was this child studying by registered home schooling or study
outside Australia?
90
Give details below
Go to next question
Primary education
Full-time secondary study
/ /
Date this child started studying at this level
Registered home schooling
Special education
Study outside Australia
13 of 58
Child 1
No
Yes
Was this child under 4 years of age during the 20132014
financial year?
Go to 97
Go to next question
86
Who are the parents of this child?
If you (and/or your partner) are the birth mother, biological
father or adoptive parent of this child at both questions 75
and 76. Go to 87
Parent 1
Is this person deceased?
No
Yes
Date of death / /
Parent 2
Is this person deceased?
No
Yes
Date of death / /
87
78 Did this child enter your (and/or your partners) care as part of
a surrogacy arrangement?
No
Yes Go to 80
Go to next question
79 Has the birth mother of this child given birth to any other
children (excluding stillborn children)?
No
Yes Go to 84
Go to 84
80 Have you (and/or your partner) previously had a child entrusted
to your care?
No
Yes
81 Did you have this child in your care for at least 13 consecutive
weeks?
No
Yes
Go to 84
Go to 84
82 Have you (and/or your partner) adopted a child before this child?
No
Yes
83 Did you (and/or your partner) adopt this child as part of a known
adoption?
No
Yes
Have you (or your partner) previously claimed Parental Leave Pay
for this child?
84
No
Yes
Do you intend to claim Parental Leave Pay for this child? 85
No
Yes
Go to 86
Go to next question
FA048.1407
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Child 1
Did this child complete a Year 12 or equivalent qualification
before 1 July 2013?
94
No
Yes Give details below
Go to 100
Certificate Number
Name of School/College/Campus
(including Australian Technical College)
Course title (e.g. NSW Higher School Certificate or
Certificate Level II in Hospitality)
Date this child first enrolled
or started study, whichever
is earlier Date completed
/ / / /
Was this child a full-time student for the entire 20132014
financial year?
No
Yes
Give details below
Go to 104
96
From To
/ / / /
Period of full-time study
Go to 101
/ / / /
Did this child repeat Year 12 during the 20132014 financial
year?
No
Yes
95
Go to next question
Go to 100
Was this child under 20 years of age on 30 June 2014? 93
Did this child cease or complete primary, full-time secondary or
special education during the 20132014 financial year?
No
Yes
91
Give details below
Go to next question
Primary education
Full-time secondary study
/ /
Date this child started
studying at this level
No
Yes
Was this child granted an exemption from studying by your state
or territory education authority?
92
Give details below
Go to 97
Primary education
Full-time secondary study
Reason for exemption
Start date
Date this circumstance
will cease or ceased
/ / / /
97 Did this child turn 1, 2 or 5 years of age during the
20132014 financial year?
No
Yes Go to next question
Go to 99
Special education
Go to 97
Special education
/ /
Date this child finished
studying at this level
No
Yes Go to next question
Do not answer anymore questions for this child.
Go to 137
FA048.1407
Was this child in education or training (including school based
apprenticeships or traineeships) during the 20132014 financial
year?
100
Course title (e.g. NSW Higher School Certificate or
Certificate Level II in Hospitality)
Was this child enrolled:
Full-time
Less than full-time Go to next question
Go to 103
No
Yes
Was there a reason this child was not in full-time education or
training during the 20132014 financial year?
101
Give details below
Go to next question
No
Yes
Go to next question
Give details below
If this child attended more than one school, attach a separate
sheet with details of each school.
Name of School/College/Campus
(including Australian Technical College)
Date this child first enrolled
or started study, whichever
is earlier
Date this child completed or
will complete this course
/ / / /
Start date
Date this circumstance
will cease or ceased
/ / / /
For a secondary or equivalent course, the course completion
day is usually the last day of the final term of your childs
secondary course this is the date given by the school.
However, if the exam period goes beyond the last day of term,
the completion day is the end of the exam period.
Please read this before answering the following question
15 of 58
Child 1
Is this child listed on a current Medicare card?
98
To receive Family Tax Benefit Part A supplement, immunisation
requirements will need to be met for the financial years
during which a child turns 1, 2 or 5 years of age.
For a list of acceptable evidence of your child meeting the
immunisation requirements, see Immunisation Details in the
Information Booklet.
To do this you need to provide details of the current Medicare
card the child is listed on so that we can confirm this childs
immunisation is up-to-date, or that they have an approved
exemption.
Please read this before answering the following question
No
Yes
Go to next question
Childs Medicare reference number (if applicable)
Reference
Number
First given name and second initial
Number on the current Medicare card
For example, exemption from study.
99 Was this child under 4 years of age on 30 June 2014?
No
Yes Go to 107
Go to next question
FA048.1407
Do you have legal or other documents to support the change of
care?
No
Yes
Go to next question
Attach a copy of this document.
No
Yes
Did this child come into your care from someone else during
the 20132014 financial year?
108
Go to 112
Who cared for this child before you?
Name
Address
Postcode
Contact phone number (if known)
( )
When did this child enter your care? 109
/ /
What periods in 20132014 did this child live with you?
From
/ / / /
/ /
/ /
/ /
110
111
To
/ /
/ /
/ /
No
Yes
Did this child receive any of the following payments or
education allowances during the 20132014 financial year?
Go to next question
Go to 106
Carer Payment
Community Development Employment Projects (CDEP)
Participant Supplement
Disability Support Pension
Disability Support Pension (Blind)
Parenting Payment
Sickness Allowance
Special Benet
Youth Allowance
Veterans' Children Education Scheme (VCES)/Military
Rehabilitation and Compensation Act Education and
Training Scheme (MRCAETS) paid by the Department of
Veterans' Affairs.
Was this child 16 years or over and had a partner during the
20132014 financial year?
$
No
Yes What was their combined adjusted taxable income?
Go to next question
103
104
Do you have a child support care determination for this child? 107
No
Yes
No
Yes
Was this childs adjusted taxable income $14,078 or more in
the 20132014 financial year?
Give details below
Go to next question
102
If this childs income for the 20132014 financial year was
$14,078 or more you are not entitled to receive family
assistance for them for that part of the 20132014 financial
year where the child income rules apply.
For more information, see Eligible child in the Information
Booklet.
$
Did this child receive ABSTUDY (do not include Schooling A)
during the 20132014 financial year?
106
No
Yes
Certain allowances can be received in addition to Family Tax
Benefit.
16 of 58
Child 1
Did this child receive payment(s) for the entire 20132014
financial year?
105
No
Yes This child is not an eligible Family Tax Benefit child
do not answer any more questions for THIS child.
Go to next question
Go to 137
FA048.1407
Please read this before answering the following question
To receive your correct entitlement of Family Tax Benefit you
should confirm your percentage of care with the other person
caring for this child.
For more information, see Shared care in the Information
Booklet.
What percentage of care did you have of this child during the
20132014 financial year?
%
Provide the periods of shared care for this child during the
20132014 financial year
If there are more dates, attach a separate sheet with details.
From To
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
OR
How many nights was this child in your care during the
20132014 financial year?
From To
/ / / /
116
117
17 of 58
Child 1
Did you have a parenting plan, court order or written agreement
for the period during the 20132014 financial year?
No
Yes
Go to 116
Attach a copy of the parenting plan, court
order or written agreement.
Did this child spend time in care with someone else other than
you (and/or your partner at 30 June 2014) such as their other
parent if you were separated, grandparent or other carer
during the 20132014 financial year (e.g. weekends, school
holidays)?
To be paid any Family Tax Benefit, you must have care of this
child for at least 35 per cent of the time during the
20132014 financial year. To be considered in your care, you
must be responsible (whether jointly or with someone else)
for their day-to-day care, welfare and development. A child
living independently is an example of someone who may not
qualify as an eligible child.
For more information, see Shared care in the Information
Booklet.
Who did this child spend time with?
No
Yes
Postcode
Name
Address
Go to 121
112
113
No
Yes
Was the parenting plan, court order or written agreement
complied with during the 20132014 financial year?
114
Was the shared care arrangement for this child for the full
20132014 financial year?
Go to 117
No
Yes
Go to next question
115
Go to 116
Go to next question
FA048.1407
Did this child leave your care for MORE than a short period
during the 20132014 financial year?
A short period is generally a period less than 4 consecutive
weeks. To be considered in your care, you must be
responsible (whether jointly or with someone else) for their
day-to-day care, welfare and development. A child living
independently is an example of someone who may not qualify
as an eligible child.
Provide the periods during which this child was not in
your care
No
Yes
Was this with your consent?
No
Yes
Did you take reasonable action to regain care of this child?
No
Yes
Did this child die during the 20132014 financial year?
If a child died, you may be eligible to receive a bereavement
payment.
No
Yes
/ /
Date of death
We will contact you to provide more information.
If there are more dates, attach a separate sheet with details.
From To
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
Go to 121
Go to next question
Go to 121
Go to next question
Please read this before answering the following question
If any dependent child in your care is from a previous
relationship, you are required to take reasonable action to
obtain a child support assessment in order to receive more
than the base rate of Family Tax Benefit Part A.
For more information, see Children from a previous
relationship in the Information Booklet.
The following questions are about child support you (and/or
your partner at 30 June 2014) were entitled to receive and
actually received during the 20132014 financial year.
Is this child from a previous relationship?
No
Yes
Go to next question
Go to 124
Did you (and/or your partner) take any action to obtain a child
support assessment for this child (e.g. by contacting Child
Support services) during the 20132014 financial year?
No
Yes
Please explain why you (and/or your partner) did not take any
action to obtain a child support assessment for this child. Please
include details, if there is any reason that makes it difficult for
you (and/or your partner) to apply for a child support assessment.
Action taken by:
You
Your partner
Go to next question
Go to 127
119
120
121
118 122
125
126
Go to 131
18 of 58
Child 1
Did you (and/or your partner) receive or were you (and/or your
partner) entitled to receive any child support for this child during
the 20132014 financial year?
No
Go to next question
Go to 135
Yes
123
Did you (and/or your partner) have a current child support
assessment for this child during the 20132014 financial year?
No Go to next question
Yes
124
If you had a child support assessment, details will
be obtained directly from Child Support services.
Your claim will remain pending until this information
is received electronically from Child Support services.
Go to 127
FA048.1407
19 of 58
Child 1
From whom were you (and/or your partner) entitled to receive
child support for this child during the 20132014 financial year?
Full name(s)
127
The details of the child support action you (and/or your
partner) have taken for this child will be obtained directly
from Child Support services. Your claim will remain pending
until this information is received from Child Support services.
Child support can include cash, capitalised maintenance/
lump sum payment(s) and non-cash amounts. Non-cash child
support includes receiving food, clothes etc from the other
parent, and also includes payment(s) made to another person
or organisation on your behalf, such as loan repayments,
school fees, rates, insurance, household expenses, child care
fees, school fees or other expenses/purchases. Non-cash
amounts must be reported as a dollar value. Capitalised
maintenance or a lump sum payment is maintenance that is
not a regular or a periodic payment and is worth more than
$1,500. It may be provided as a lump sum payment (i.e. a
cash amount) or a property settlement (i.e. your home, a car,
a business etc).
For more information see the Information Booklet.
Please read this before answering the following questions 128
Did you (and/or your partner) receive any child support for this
child that was not part of a child support assessment (i.e. you
received more than the child support assessed amount) for any
period you were Child Support services collect during the
20132014 financial year?
No
Yes
Go to next question
Did you receive any voluntary child support for this child during
the 20132014 financial year?
131
$
No
Yes
Go to 135
How much was received
Go to 134
Did you (and/or your partner) discharge any child support
arrears during the 20132014 financial year?
133
No
Yes
Go to next question
What was the amount of arrears you discharged?
$
/ /
On what date did you discharge the arrears?
Discharged child support arrears
If you changed from Child Support services collect to private
collect and you had child support owing to you, you may have
elected to discharge any amount owed to you from the Child
Support services collect period. You must tell us if you have
discharged arrears, or you later discharge arrears.
For more information, see Children from a previous
relationship in the Information Booklet.
Please read this before answering the following questions 132
Did you (and/or your partner), change from Child Support
services collect to private collect, at any time during the
20132014 financial year?
No
Yes
Go to 134
Go to next question
Did you (and/or your partner) receive any additional child
support for this child that was not part of a child support
assessment (i.e. you received more than the child support
assessed amount) for any period you were private collect during
the 20132014 financial year?
129
You will need to tell Child Support services if you
received any additional child support (including
cash, a lump sum payment or non cash).
Go to next question
No
Yes
Go to 132
Go to next question
Did this amount include any child support arrears that were
owed to you for a private collect period before 1 July 2012?
130
No
Yes
Go to 132
What was the total additional child support received
for this child during the 20132014 financial year?
$
Child support arrears relate to a child support amount owed
to you when you were a private collect customer, and you
privately collected an amount that was less than your child
support assessment.
Please read this before answering the following question
Go to 132
FA048.1407
Did you (and/or your partner) receive any child support in
relation to this child having a disability or learning difficulty
during the 20132014 financial year?
No
Yes
Go to next question
How much was received:
$
Through Child Support services
$
Privately
20 of 58
Child 1
134
Apart from Family Tax Benefit, there are other payments or
assistance that families may be entitled to receive.
Please read this before answering the following questions 135
Is this child an orphan? 136
No
Yes
Go to next question
Does this child have a disability?
No
Yes
Go online www.humanservices.gov.au/carers for
more information about Carer Allowance and/or
Carer Payment.
Go to next question
For more information and our definition of an orphan, see
Double Orphan Pension in the Information Booklet.
Did you have another child, during the 20132014 financial year,
for whom you wish to claim a lump sum payment of Family Tax
Benefit?
No
Yes
Go to 138 on page 48
137
Go to next question on the next page
FA048.1407
21 of 58
Child 2
Childs first given name
Childs family name 68
70 Childs sex
Male
Female
Childs second given name
Childs date of birth 71
/ /
Has this child been known by any other names?
No
Yes List the other names
69
Go to next question
What is this childs country of birth? 72
Has this child EVER lived or travelled outside Australia, including
short trips and holidays?
73
The answer to this question may enable Human Services to
access electronic records held by Australias immigration
department and help verify this childs Australian residence.
No
Yes Give details below
Go to next question
Passport number
Country of issue
Was this child part of a multiple birth, multiple entrustment to
care or multiple adoption?
74
No
Yes
75 The term parent refers to a natural parent or a person who
is legally responsible for a child born through an assisted
conception procedure.
Your partners (if you have one) relationship to this child
Give details below
Partner of birth mother
Biological father
Partner of biological father
Grandparent
Other
Birth mother
Your relationship to this child 76
Adoptive parent
Foster parent (formal)
Foster parent (informal)
Give details below
Partner of birth mother
Biological father
Partner of biological father
Grandparent
Other
Birth mother
Adoptive parent
Foster parent (formal)
Foster parent (informal)
Go to next question
Go to 79
Go to 82
Go to 78
Go to 78
Go to 80
Go to 80
Go to 80
Go to 80
77 Have you given birth to any other children (excluding stillborn
children) before this child?
No
Yes Go to 84
Go to 84
FA048.1407
22 of 58
Child 2
No
Yes
Was this child under 16 years of age on 30 June 2014?
Go to next question
Go to 93
88
Was this child studying during the 20132014 financial year? 89
No
Yes Highest level of study during 20132014
Go to 92
No
Yes
Was this child studying by registered home schooling or study
outside Australia?
90
Give details below
Go to next question
Primary education
Full-time secondary study
/ /
Date this child started studying at this level
Registered home schooling
Special education
Study outside Australia
78 Did this child enter your (and/or your partners) care as part of
a surrogacy arrangement?
No
Yes Go to 80
Go to next question
79 Has the birth mother of this child given birth to any other
children (excluding stillborn children)?
No
Yes Go to 84
Go to 84
80 Have you (and/or your partner) previously had a child entrusted
to your care?
No
Yes
81 Did you have this child in your care for at least 13 consecutive
weeks?
No
Yes
Go to 84
Go to 84
82 Have you (and/or your partner) adopted a child before this child?
No
Yes
83 Did you (and/or your partner) adopt this child as part of a known
adoption?
No
Yes
Have you (or your partner) previously claimed Parental Leave Pay
for this child?
84
No
Yes
Do you intend to claim Parental Leave Pay for this child? 85
No
Yes
No
Yes
Was this child under 4 years of age during the 20132014
financial year?
Go to 97
Go to next question
86
Who are the parents of this child?
If you (and/or your partner) are the birth mother, biological
father or adoptive parent of this child at both questions 75
and 76. Go to 87
Parent 1
Is this person deceased?
No
Yes
Date of death / /
Parent 2
Is this person deceased?
No
Yes
Date of death / /
87
Go to 86
Go to next question
FA048.1407
23 of 58
Child 2
Did this child complete a Year 12 or equivalent qualification
before 1 July 2013?
94
No
Yes Give details below
Go to 100
Certificate Number
Name of School/College/Campus
(including Australian Technical College)
Course title (e.g. NSW Higher School Certificate or
Certificate Level II in Hospitality)
Date this child first enrolled
or started study, whichever
is earlier Date completed
/ / / /
Was this child a full-time student for the entire 20132014
financial year?
No
Yes
Give details below
Go to 104
96
From To
/ / / /
Period of full-time study
Go to 101
/ / / /
Did this child repeat Year 12 during the 20132014 financial
year?
No
Yes
95
Go to next question
Go to 100
Was this child under 20 years of age on 30 June 2014? 93
Did this child cease or complete primary, full-time secondary or
special education during the 20132014 financial year?
No
Yes
91
Give details below
Go to next question
Primary education
Full-time secondary study
/ /
Date this child started
studying at this level
No
Yes
Was this child granted an exemption from studying by your state
or territory education authority?
92
Give details below
Go to 97
Primary education
Full-time secondary study
Reason for exemption
Start date
Date this circumstance
will cease or ceased
/ / / /
97 Did this child turn 1, 2 or 5 years of age during the
20132014 financial year?
No
Yes Go to next question
Go to 99
Special education
Go to 97
Special education
/ /
Date this child finished
studying at this level
No
Yes Go to next question
Do not answer anymore questions for this child.
Go to 137
FA048.1407
24 of 58
Child 2
Was this child in education or training (including school based
apprenticeships or traineeships) during the 20132014 financial
year?
100
Course title (e.g. NSW Higher School Certificate or
Certificate Level II in Hospitality)
Was this child enrolled:
Full-time
Less than full-time Go to next question
Go to 103
No
Yes
Was there a reason this child was not in full-time education or
training during the 20132014 financial year?
101
Give details below
Go to next question
No
Yes
Go to next question
Give details below
If this child attended more than one school, attach a separate
sheet with details of each school.
Name of School/College/Campus
(including Australian Technical College)
Date this child first enrolled
or started study, whichever
is earlier
Date this child completed or
will complete this course
/ / / /
Start date
Date this circumstance
will cease or ceased
/ / / /
For a secondary or equivalent course, the course completion
day is usually the last day of the final term of your childs
secondary course this is the date given by the school.
However, if the exam period goes beyond the last day of term,
the completion day is the end of the exam period.
Please read this before answering the following question
Is this child listed on a current Medicare card?
98
To receive Family Tax Benefit Part A supplement, immunisation
requirements will need to be met for the financial years
during which a child turns 1, 2 or 5 years of age.
For a list of acceptable evidence of your child meeting the
immunisation requirements, see Immunisation Details in the
Information Booklet.
To do this you need to provide details of the current Medicare
card the child is listed on so that we can confirm this childs
immunisation is up-to-date, or that they have an approved
exemption.
Please read this before answering the following question
No
Yes
Go to next question
Childs Medicare reference number (if applicable)
Reference
Number
First given name and second initial
Number on the current Medicare card
For example, exemption from study.
99 Was this child under 4 years of age on 30 June 2014?
No
Yes Go to 107
Go to next question
FA048.1407
25 of 58
Child 2
Do you have legal or other documents to support the change of
care?
No
Yes
Go to next question
Attach a copy of this document.
No
Yes
Did this child come into your care from someone else during
the 20132014 financial year?
108
Go to 112
Who cared for this child before you?
Name
Address
Postcode
Contact phone number (if known)
( )
When did this child enter your care? 109
/ /
What periods in 20132014 did this child live with you?
From
/ / / /
/ /
/ /
/ /
110
111
To
/ /
/ /
/ /
No
Yes
Did this child receive any of the following payments or
education allowances during the 20132014 financial year?
Go to next question
Go to 106
Carer Payment
Community Development Employment Projects (CDEP)
Participant Supplement
Disability Support Pension
Disability Support Pension (Blind)
Parenting Payment
Sickness Allowance
Special Benet
Youth Allowance
Veterans' Children Education Scheme (VCES)/Military
Rehabilitation and Compensation Act Education and
Training Scheme (MRCAETS) paid by the Department of
Veterans' Affairs.
Was this child 16 years or over and had a partner during the
20132014 financial year?
$
No
Yes What was their combined adjusted taxable income?
Go to next question
103
104
Do you have a child support care determination for this child? 107
No
Yes
No
Yes
Was this childs adjusted taxable income $14,078 or more in
the 20132014 financial year?
Give details below
Go to next question
102
If this childs income for the 20132014 financial year was
$14,078 or more you are not entitled to receive family
assistance for them for that part of the 20132014 financial
year where the child income rules apply.
For more information, see Eligible child in the Information
Booklet.
$
Did this child receive ABSTUDY (do not include Schooling A)
during the 20132014 financial year?
106
No
Yes
Certain allowances can be received in addition to Family Tax
Benefit.
Did this child receive payment(s) for the entire 20132014
financial year?
105
No
Yes This child is not an eligible Family Tax Benefit child
do not answer any more questions for THIS child.
Go to next question
Go to 137
FA048.1407
26 of 58
Child 2
Please read this before answering the following question
To receive your correct entitlement of Family Tax Benefit you
should confirm your percentage of care with the other person
caring for this child.
For more information, see Shared care in the Information
Booklet.
What percentage of care did you have of this child during the
20132014 financial year?
%
Provide the periods of shared care for this child during the
20132014 financial year
If there are more dates, attach a separate sheet with details.
From To
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
OR
How many nights was this child in your care during the
20132014 financial year?
From To
/ / / /
116
117
Did you have a parenting plan, court order or written agreement
for the period during the 20132014 financial year?
No
Yes
Go to 116
Attach a copy of the parenting plan, court
order or written agreement.
Did this child spend time in care with someone else other than
you (and/or your partner at 30 June 2014) such as their other
parent if you were separated, grandparent or other carer
during the 20132014 financial year (e.g. weekends, school
holidays)?
To be paid any Family Tax Benefit, you must have care of this
child for at least 35 per cent of the time during the
20132014 financial year. To be considered in your care, you
must be responsible (whether jointly or with someone else)
for their day-to-day care, welfare and development. A child
living independently is an example of someone who may not
qualify as an eligible child.
For more information, see Shared care in the Information
Booklet.
Who did this child spend time with?
No
Yes
Postcode
Name
Address
Go to 121
112
113
No
Yes
Was the parenting plan, court order or written agreement
complied with during the 20132014 financial year?
114
Was the shared care arrangement for this child for the full
20132014 financial year?
Go to 117
No
Yes
Go to next question
115
Go to 116
Go to next question
FA048.1407
27 of 58
Child 2
Did this child leave your care for MORE than a short period
during the 20132014 financial year?
A short period is generally a period less than 4 consecutive
weeks. To be considered in your care, you must be
responsible (whether jointly or with someone else) for their
day-to-day care, welfare and development. A child living
independently is an example of someone who may not qualify
as an eligible child.
Provide the periods during which this child was not in
your care
No
Yes
Was this with your consent?
No
Yes
Did you take reasonable action to regain care of this child?
No
Yes
Did this child die during the 20132014 financial year?
If a child died, you may be eligible to receive a bereavement
payment.
No
Yes
/ /
Date of death
We will contact you to provide more information.
If there are more dates, attach a separate sheet with details.
From To
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
Go to 121
Go to next question
Go to 121
Go to next question
Please read this before answering the following question
If any dependent child in your care is from a previous
relationship, you are required to take reasonable action to
obtain a child support assessment in order to receive more
than the base rate of Family Tax Benefit Part A.
For more information, see Children from a previous
relationship in the Information Booklet.
The following questions are about child support you (and/or
your partner at 30 June 2014) were entitled to receive and
actually received during the 20132014 financial year.
Is this child from a previous relationship?
No
Yes
Go to next question
Go to 124
Did you (and/or your partner) take any action to obtain a child
support assessment for this child (e.g. by contacting Child
Support services) during the 20132014 financial year?
No
Yes
Please explain why you (and/or your partner) did not take any
action to obtain a child support assessment for this child. Please
include details, if there is any reason that makes it difficult for
you (and/or your partner) to apply for a child support assessment.
Action taken by:
You
Your partner
Go to next question
Go to 127
119
120
121
118 122
125
126
Go to 131
Did you (and/or your partner) receive or were you (and/or your
partner) entitled to receive any child support for this child during
the 20132014 financial year?
No
Go to next question
Go to 135
Yes
123
Did you (and/or your partner) have a current child support
assessment for this child during the 20132014 financial year?
No Go to next question
Yes
124
If you had a child support assessment, details will
be obtained directly from Child Support services.
Your claim will remain pending until this information
is received electronically from Child Support services.
Go to 127
FA048.1407
28 of 58
Child 2
From whom were you (and/or your partner) entitled to receive
child support for this child during the 20132014 financial year?
Full name(s)
127
The details of the child support action you (and/or your
partner) have taken for this child will be obtained directly
from Child Support services. Your claim will remain pending
until this information is received from Child Support services.
Child support can include cash, capitalised maintenance/
lump sum payment(s) and non-cash amounts. Non-cash child
support includes receiving food, clothes etc from the other
parent, and also includes payment(s) made to another person
or organisation on your behalf, such as loan repayments,
school fees, rates, insurance, household expenses, child care
fees, school fees or other expenses/purchases. Non-cash
amounts must be reported as a dollar value. Capitalised
maintenance or a lump sum payment is maintenance that is
not a regular or a periodic payment and is worth more than
$1,500. It may be provided as a lump sum payment (i.e. a
cash amount) or a property settlement (i.e. your home, a car,
a business etc).
For more information see the Information Booklet.
Please read this before answering the following questions 128
Did you (and/or your partner) receive any child support for this
child that was not part of a child support assessment (i.e. you
received more than the child support assessed amount) for any
period you were Child Support services collect during the
20132014 financial year?
No
Yes
Go to next question
Did you receive any voluntary child support for this child during
the 20132014 financial year?
131
$
No
Yes
Go to 135
How much was received
Go to 134
Did you (and/or your partner) discharge any child support
arrears during the 20132014 financial year?
133
No
Yes
Go to next question
What was the amount of arrears you discharged?
$
/ /
On what date did you discharge the arrears?
Discharged child support arrears
If you changed from Child Support services collect to private
collect and you had child support owing to you, you may have
elected to discharge any amount owed to you from the Child
Support services collect period. You must tell us if you have
discharged arrears, or you later discharge arrears.
For more information, see Children from a previous
relationship in the Information Booklet.
Please read this before answering the following questions 132
Did you (and/or your partner), change from Child Support
services collect to private collect, at any time during the
20132014 financial year?
No
Yes
Go to 134
Go to next question
Did you (and/or your partner) receive any additional child
support for this child that was not part of a child support
assessment (i.e. you received more than the child support
assessed amount) for any period you were private collect during
the 20132014 financial year?
129
You will need to tell Child Support services if you
received any additional child support (including
cash, a lump sum payment or non cash).
Go to next question
No
Yes
Go to 132
Go to next question
Did this amount include any child support arrears that were
owed to you for a private collect period before 1 July 2012?
130
No
Yes
Go to 132
What was the total additional child support received
for this child during the 20132014 financial year?
$
Child support arrears relate to a child support amount owed
to you when you were a private collect customer, and you
privately collected an amount that was less than your child
support assessment.
Please read this before answering the following question
Go to 132
FA048.1407
Did you (and/or your partner) receive any child support in
relation to this child having a disability or learning difficulty
during the 20132014 financial year?
No
Yes
Go to next question
How much was received:
$
Through Child Support services
$
Privately
29 of 58
Child 2
134
Apart from Family Tax Benefit, there are other payments or
assistance that families may be entitled to receive.
Please read this before answering the following questions 135
Is this child an orphan? 136
No
Yes
Go to next question
Does this child have a disability?
No
Yes
Go online www.humanservices.gov.au/carers for
more information about Carer Allowance and/or
Carer Payment.
Go to next question
For more information and our definition of an orphan, see
Double Orphan Pension in the Information Booklet.
Did you have another child, during the 20132014 financial year,
for whom you wish to claim a lump sum payment of Family Tax
Benefit?
No
Yes
Go to 138 on page 48
137
Go to next question on the next page
FA048.1407
30 of 58
Child 3
Childs first given name
Childs family name 68
70 Childs sex
Male
Female
Childs second given name
Childs date of birth 71
/ /
Has this child been known by any other names?
No
Yes List the other names
69
Go to next question
What is this childs country of birth? 72
Has this child EVER lived or travelled outside Australia, including
short trips and holidays?
73
The answer to this question may enable Human Services to
access electronic records held by Australias immigration
department and help verify this childs Australian residence.
No
Yes Give details below
Go to next question
Passport number
Country of issue
Was this child part of a multiple birth, multiple entrustment to
care or multiple adoption?
74
No
Yes
75 The term parent refers to a natural parent or a person who
is legally responsible for a child born through an assisted
conception procedure.
Your partners (if you have one) relationship to this child
Give details below
Partner of birth mother
Biological father
Partner of biological father
Grandparent
Other
Birth mother
Your relationship to this child 76
Adoptive parent
Foster parent (formal)
Foster parent (informal)
Give details below
Partner of birth mother
Biological father
Partner of biological father
Grandparent
Other
Birth mother
Adoptive parent
Foster parent (formal)
Foster parent (informal)
Go to next question
Go to 79
Go to 82
Go to 78
Go to 78
Go to 80
Go to 80
Go to 80
Go to 80
77 Have you given birth to any other children (excluding stillborn
children) before this child?
No
Yes Go to 84
Go to 84
FA048.1407
31 of 58
Child 3
No
Yes
Was this child under 16 years of age on 30 June 2014?
Go to next question
Go to 93
88
Was this child studying during the 20132014 financial year? 89
No
Yes Highest level of study during 20132014
Go to 92
No
Yes
Was this child studying by registered home schooling or study
outside Australia?
90
Give details below
Go to next question
Primary education
Full-time secondary study
/ /
Date this child started studying at this level
Registered home schooling
Special education
Study outside Australia
No
Yes
Was this child under 4 years of age during the 20132014
financial year?
Go to 97
Go to next question
86
Who are the parents of this child?
If you (and/or your partner) are the birth mother, biological
father or adoptive parent of this child at both questions 75
and 76. Go to 87
Parent 1
Is this person deceased?
No
Yes
Date of death / /
Parent 2
Is this person deceased?
No
Yes
Date of death / /
87
78 Did this child enter your (and/or your partners) care as part of
a surrogacy arrangement?
No
Yes Go to 80
Go to next question
79 Has the birth mother of this child given birth to any other
children (excluding stillborn children)?
No
Yes Go to 84
Go to 84
80 Have you (and/or your partner) previously had a child entrusted
to your care?
No
Yes
81 Did you have this child in your care for at least 13 consecutive
weeks?
No
Yes
Go to 84
Go to 84
82 Have you (and/or your partner) adopted a child before this child?
No
Yes
83 Did you (and/or your partner) adopt this child as part of a known
adoption?
No
Yes
Have you (or your partner) previously claimed Parental Leave Pay
for this child?
84
No
Yes
Do you intend to claim Parental Leave Pay for this child? 85
No
Yes
Go to 86
Go to next question
FA048.1407
32 of 58
Child 3
Did this child complete a Year 12 or equivalent qualification
before 1 July 2013?
94
No
Yes Give details below
Go to 100
Certificate Number
Name of School/College/Campus
(including Australian Technical College)
Course title (e.g. NSW Higher School Certificate or
Certificate Level II in Hospitality)
Date this child first enrolled
or started study, whichever
is earlier Date completed
/ / / /
Was this child a full-time student for the entire 20132014
financial year?
No
Yes
Give details below
Go to 104
96
From To
/ / / /
Period of full-time study
Go to 101
/ / / /
Did this child repeat Year 12 during the 20132014 financial
year?
No
Yes
95
Go to next question
Go to 100
Was this child under 20 years of age on 30 June 2014? 93
Did this child cease or complete primary, full-time secondary or
special education during the 20132014 financial year?
No
Yes
91
Give details below
Go to next question
Primary education
Full-time secondary study
/ /
Date this child started
studying at this level
No
Yes
Was this child granted an exemption from studying by your state
or territory education authority?
92
Give details below
Go to 97
Primary education
Full-time secondary study
Reason for exemption
Start date
Date this circumstance
will cease or ceased
/ / / /
97 Did this child turn 1, 2 or 5 years of age during the
20132014 financial year?
No
Yes Go to next question
Go to 99
Special education
Go to 97
Special education
/ /
Date this child finished
studying at this level
No
Yes Go to next question
Do not answer anymore questions for this child.
Go to 137
FA048.1407
33 of 58
Child 3
Was this child in education or training (including school based
apprenticeships or traineeships) during the 20132014 financial
year?
100
Course title (e.g. NSW Higher School Certificate or
Certificate Level II in Hospitality)
Was this child enrolled:
Full-time
Less than full-time Go to next question
Go to 103
No
Yes
Was there a reason this child was not in full-time education or
training during the 20132014 financial year?
101
Give details below
Go to next question
No
Yes
Go to next question
Give details below
If this child attended more than one school, attach a separate
sheet with details of each school.
Name of School/College/Campus
(including Australian Technical College)
Date this child first enrolled
or started study, whichever
is earlier
Date this child completed or
will complete this course
/ / / /
Start date
Date this circumstance
will cease or ceased
/ / / /
For a secondary or equivalent course, the course completion
day is usually the last day of the final term of your childs
secondary course this is the date given by the school.
However, if the exam period goes beyond the last day of term,
the completion day is the end of the exam period.
Please read this before answering the following question
Is this child listed on a current Medicare card?
98
To receive Family Tax Benefit Part A supplement, immunisation
requirements will need to be met for the financial years
during which a child turns 1, 2 or 5 years of age.
For a list of acceptable evidence of your child meeting the
immunisation requirements, see Immunisation Details in the
Information Booklet.
To do this you need to provide details of the current Medicare
card the child is listed on so that we can confirm this childs
immunisation is up-to-date, or that they have an approved
exemption.
Please read this before answering the following question
No
Yes
Go to next question
Childs Medicare reference number (if applicable)
Reference
Number
First given name and second initial
Number on the current Medicare card
For example, exemption from study.
99 Was this child under 4 years of age on 30 June 2014?
No
Yes Go to 107
Go to next question
FA048.1407
34 of 58
Child 3
Do you have legal or other documents to support the change of
care?
No
Yes
Go to next question
Attach a copy of this document.
No
Yes
Did this child come into your care from someone else during
the 20132014 financial year?
108
Go to 112
Who cared for this child before you?
Name
Address
Postcode
Contact phone number (if known)
( )
When did this child enter your care? 109
/ /
What periods in 20132014 did this child live with you?
From
/ / / /
/ /
/ /
/ /
110
111
To
/ /
/ /
/ /
No
Yes
Did this child receive any of the following payments or
education allowances during the 20132014 financial year?
Go to next question
Go to 106
Carer Payment
Community Development Employment Projects (CDEP)
Participant Supplement
Disability Support Pension
Disability Support Pension (Blind)
Parenting Payment
Sickness Allowance
Special Benet
Youth Allowance
Veterans' Children Education Scheme (VCES)/Military
Rehabilitation and Compensation Act Education and
Training Scheme (MRCAETS) paid by the Department of
Veterans' Affairs.
Was this child 16 years or over and had a partner during the
20132014 financial year?
$
No
Yes What was their combined adjusted taxable income?
Go to next question
103
104
Do you have a child support care determination for this child? 107
No
Yes
No
Yes
Was this childs adjusted taxable income $14,078 or more in
the 20132014 financial year?
Give details below
Go to next question
102
If this childs income for the 20132014 financial year was
$14,078 or more you are not entitled to receive family
assistance for them for that part of the 20132014 financial
year where the child income rules apply.
For more information, see Eligible child in the Information
Booklet.
$
Did this child receive ABSTUDY (do not include Schooling A)
during the 20132014 financial year?
106
No
Yes
Certain allowances can be received in addition to Family Tax
Benefit.
Did this child receive payment(s) for the entire 20132014
financial year?
105
No
Yes This child is not an eligible Family Tax Benefit child
do not answer any more questions for THIS child.
Go to next question
Go to 137
FA048.1407
35 of 58
Child 3
Please read this before answering the following question
To receive your correct entitlement of Family Tax Benefit you
should confirm your percentage of care with the other person
caring for this child.
For more information, see Shared care in the Information
Booklet.
What percentage of care did you have of this child during the
20132014 financial year?
%
Provide the periods of shared care for this child during the
20132014 financial year
If there are more dates, attach a separate sheet with details.
From To
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
OR
How many nights was this child in your care during the
20132014 financial year?
From To
/ / / /
116
117
Did you have a parenting plan, court order or written agreement
for the period during the 20132014 financial year?
No
Yes
Go to 116
Attach a copy of the parenting plan, court
order or written agreement.
Did this child spend time in care with someone else other than
you (and/or your partner at 30 June 2014) such as their other
parent if you were separated, grandparent or other carer
during the 20132014 financial year (e.g. weekends, school
holidays)?
To be paid any Family Tax Benefit, you must have care of this
child for at least 35 per cent of the time during the
20132014 financial year. To be considered in your care, you
must be responsible (whether jointly or with someone else)
for their day-to-day care, welfare and development. A child
living independently is an example of someone who may not
qualify as an eligible child.
For more information, see Shared care in the Information
Booklet.
Who did this child spend time with?
No
Yes
Postcode
Name
Address
Go to 121
112
113
No
Yes
Was the parenting plan, court order or written agreement
complied with during the 20132014 financial year?
114
Was the shared care arrangement for this child for the full
20132014 financial year?
Go to 117
No
Yes
Go to next question
115
Go to 116
Go to next question
FA048.1407
36 of 58
Child 3
Did this child leave your care for MORE than a short period
during the 20132014 financial year?
A short period is generally a period less than 4 consecutive
weeks. To be considered in your care, you must be
responsible (whether jointly or with someone else) for their
day-to-day care, welfare and development. A child living
independently is an example of someone who may not qualify
as an eligible child.
Provide the periods during which this child was not in
your care
No
Yes
Was this with your consent?
No
Yes
Did you take reasonable action to regain care of this child?
No
Yes
Did this child die during the 20132014 financial year?
If a child died, you may be eligible to receive a bereavement
payment.
No
Yes
/ /
Date of death
We will contact you to provide more information.
If there are more dates, attach a separate sheet with details.
From To
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
Go to 121
Go to next question
Go to 121
Go to next question
Please read this before answering the following question
If any dependent child in your care is from a previous
relationship, you are required to take reasonable action to
obtain a child support assessment in order to receive more
than the base rate of Family Tax Benefit Part A.
For more information, see Children from a previous
relationship in the Information Booklet.
The following questions are about child support you (and/or
your partner at 30 June 2014) were entitled to receive and
actually received during the 20132014 financial year.
Is this child from a previous relationship?
No
Yes
Go to next question
Go to 124
Did you (and/or your partner) take any action to obtain a child
support assessment for this child (e.g. by contacting Child
Support services) during the 20132014 financial year?
No
Yes
Please explain why you (and/or your partner) did not take any
action to obtain a child support assessment for this child. Please
include details, if there is any reason that makes it difficult for
you (and/or your partner) to apply for a child support assessment.
Action taken by:
You
Your partner
Go to next question
Go to 127
119
120
121
118 122
125
126
Go to 131
Did you (and/or your partner) receive or were you (and/or your
partner) entitled to receive any child support for this child during
the 20132014 financial year?
No
Go to next question
Go to 135
Yes
123
Did you (and/or your partner) have a current child support
assessment for this child during the 20132014 financial year?
No Go to next question
Yes
124
If you had a child support assessment, details will
be obtained directly from Child Support services.
Your claim will remain pending until this information
is received electronically from Child Support services.
Go to 127
FA048.1407
37 of 58
Child 3
From whom were you (and/or your partner) entitled to receive
child support for this child during the 20132014 financial year?
Full name(s)
127
The details of the child support action you (and/or your
partner) have taken for this child will be obtained directly
from Child Support services. Your claim will remain pending
until this information is received from Child Support services.
Child support can include cash, capitalised maintenance/
lump sum payment(s) and non-cash amounts. Non-cash child
support includes receiving food, clothes etc from the other
parent, and also includes payment(s) made to another person
or organisation on your behalf, such as loan repayments,
school fees, rates, insurance, household expenses, child care
fees, school fees or other expenses/purchases. Non-cash
amounts must be reported as a dollar value. Capitalised
maintenance or a lump sum payment is maintenance that is
not a regular or a periodic payment and is worth more than
$1,500. It may be provided as a lump sum payment (i.e. a
cash amount) or a property settlement (i.e. your home, a car,
a business etc).
For more information see the Information Booklet.
Please read this before answering the following questions 128
Did you (and/or your partner) receive any child support for this
child that was not part of a child support assessment (i.e. you
received more than the child support assessed amount) for any
period you were Child Support services collect during the
20132014 financial year?
No
Yes
Go to next question
Did you receive any voluntary child support for this child during
the 20132014 financial year?
131
$
No
Yes
Go to 135
How much was received
Go to 134
Did you (and/or your partner) discharge any child support
arrears during the 20132014 financial year?
133
No
Yes
Go to next question
What was the amount of arrears you discharged?
$
/ /
On what date did you discharge the arrears?
Discharged child support arrears
If you changed from Child Support services collect to private
collect and you had child support owing to you, you may have
elected to discharge any amount owed to you from the Child
Support services collect period. You must tell us if you have
discharged arrears, or you later discharge arrears.
For more information, see Children from a previous
relationship in the Information Booklet.
Please read this before answering the following questions 132
Did you (and/or your partner), change from Child Support
services collect to private collect, at any time during the
20132014 financial year?
No
Yes
Go to 134
Go to next question
Did you (and/or your partner) receive any additional child
support for this child that was not part of a child support
assessment (i.e. you received more than the child support
assessed amount) for any period you were private collect during
the 20132014 financial year?
129
You will need to tell Child Support services if you
received any additional child support (including
cash, a lump sum payment or non cash).
Go to next question
No
Yes
Go to 132
Go to next question
Did this amount include any child support arrears that were
owed to you for a private collect period before 1 July 2012?
130
No
Yes
Go to 132
What was the total additional child support received
for this child during the 20132014 financial year?
$
Child support arrears relate to a child support amount owed
to you when you were a private collect customer, and you
privately collected an amount that was less than your child
support assessment.
Please read this before answering the following question
Go to 132
FA048.1407
Did you (and/or your partner) receive any child support in
relation to this child having a disability or learning difficulty
during the 20132014 financial year?
No
Yes
Go to next question
How much was received:
$
Through Child Support services
$
Privately
38 of 58
Child 3
134
135
Apart from Family Tax Benefit, there are other payments or
assistance that families may be entitled to receive.
Please read this before answering the following questions
Is this child an orphan? 136
No
Yes
Go to next question
Does this child have a disability?
No
Yes
Go online www.humanservices.gov.au/carers for
more information about Carer Allowance and/or
Carer Payment.
Go to next question
For more information and our definition of an orphan, see
Double Orphan Pension in the Information Booklet.
Did you have another child, during the 20132014 financial year,
for whom you wish to claim a lump sum payment of Family Tax
Benefit?
No
Yes
Go to 138 on page 48
137
Go to next question on the next page
FA048.1407
39 of 58
Child 4
Childs first given name
Childs family name 68
70 Childs sex
Male
Female
Childs second given name
Childs date of birth 71
/ /
Has this child been known by any other names?
No
Yes List the other names
69
Go to next question
What is this childs country of birth? 72
Has this child EVER lived or travelled outside Australia, including
short trips and holidays?
73
The answer to this question may enable Human Services to
access electronic records held by Australias immigration
department and help verify this childs Australian residence.
No
Yes Give details below
Go to next question
Passport number
Country of issue
Was this child part of a multiple birth, multiple entrustment to
care or multiple adoption?
74
No
Yes
75 The term parent refers to a natural parent or a person who
is legally responsible for a child born through an assisted
conception procedure.
Your partners (if you have one) relationship to this child
Give details below
Partner of birth mother
Biological father
Partner of biological father
Grandparent
Other
Birth mother
Your relationship to this child 76
Adoptive parent
Foster parent (formal)
Foster parent (informal)
Give details below
Partner of birth mother
Biological father
Partner of biological father
Grandparent
Other
Birth mother
Adoptive parent
Foster parent (formal)
Foster parent (informal)
Go to next question
Go to 79
Go to 82
Go to 78
Go to 78
Go to 80
Go to 80
Go to 80
Go to 80
77 Have you given birth to any other children (excluding stillborn
children) before this child?
No
Yes Go to 84
Go to 84
FA048.1407
40 of 58
Child 4
No
Yes
Was this child under 16 years of age on 30 June 2014?
Go to next question
Go to 93
88
Was this child studying during the 20132014 financial year? 89
No
Yes Highest level of study during 20132014
Go to 92
No
Yes
Was this child studying by registered home schooling or study
outside Australia?
90
Give details below
Go to next question
Primary education
Full-time secondary study
/ /
Date this child started studying at this level
Registered home schooling
Special education
Study outside Australia
No
Yes
Was this child under 4 years of age during the 20132014
financial year?
Go to 97
Go to next question
86
Who are the parents of this child?
If you (and/or your partner) are the birth mother, biological
father or adoptive parent of this child at both questions 75
and 76. Go to 87
Parent 1
Is this person deceased?
No
Yes
Date of death / /
Parent 2
Is this person deceased?
No
Yes
Date of death / /
87
78 Did this child enter your (and/or your partners) care as part of
a surrogacy arrangement?
No
Yes Go to 80
Go to next question
79 Has the birth mother of this child given birth to any other
children (excluding stillborn children)?
No
Yes Go to 84
Go to 84
80 Have you (and/or your partner) previously had a child entrusted
to your care?
No
Yes
81 Did you have this child in your care for at least 13 consecutive
weeks?
No
Yes
Go to 84
Go to 84
82 Have you (and/or your partner) adopted a child before this child?
No
Yes
83 Did you (and/or your partner) adopt this child as part of a known
adoption?
No
Yes
Have you (or your partner) previously claimed Parental Leave Pay
for this child?
84
No
Yes
Do you intend to claim Parental Leave Pay for this child? 85
No
Yes
Go to 86
Go to next question
FA048.1407
41 of 58
Child 4
Did this child complete a Year 12 or equivalent qualification
before 1 July 2013?
94
No
Yes Give details below
Go to 100
Certificate Number
Name of School/College/Campus
(including Australian Technical College)
Course title (e.g. NSW Higher School Certificate or
Certificate Level II in Hospitality)
Date this child first enrolled
or started study, whichever
is earlier Date completed
/ / / /
Was this child a full-time student for the entire 20132014
financial year?
No
Yes
Give details below
Go to 104
96
From To
/ / / /
Period of full-time study
Go to 101
/ / / /
Did this child repeat Year 12 during the 20132014 financial
year?
No
Yes
95
Go to next question
Go to 100
Was this child under 20 years of age on 30 June 2014? 93
Did this child cease or complete primary, full-time secondary or
special education during the 20132014 financial year?
No
Yes
91
Give details below
Go to next question
Primary education
Full-time secondary study
/ /
Date this child started
studying at this level
No
Yes
Was this child granted an exemption from studying by your state
or territory education authority?
92
Give details below
Go to 97
Primary education
Full-time secondary study
Reason for exemption
Start date
Date this circumstance
will cease or ceased
/ / / /
97 Did this child turn 1, 2 or 5 years of age during the
20132014 financial year?
No
Yes Go to next question
Go to 99
Special education
Go to 97
Special education
/ /
Date this child finished
studying at this level
No
Yes Go to next question
Do not answer anymore questions for this child.
Go to 137
FA048.1407
42 of 58
Child 4
Was this child in education or training (including school based
apprenticeships or traineeships) during the 20132014 financial
year?
100
Course title (e.g. NSW Higher School Certificate or
Certificate Level II in Hospitality)
Was this child enrolled:
Full-time
Less than full-time Go to next question
Go to 103
No
Yes
Was there a reason this child was not in full-time education or
training during the 20132014 financial year?
101
Give details below
Go to next question
No
Yes
Go to next question
Give details below
If this child attended more than one school, attach a separate
sheet with details of each school.
Name of School/College/Campus
(including Australian Technical College)
Date this child first enrolled
or started study, whichever
is earlier
Date this child completed or
will complete this course
/ / / /
Start date
Date this circumstance
will cease or ceased
/ / / /
For a secondary or equivalent course, the course completion
day is usually the last day of the final term of your childs
secondary course this is the date given by the school.
However, if the exam period goes beyond the last day of term,
the completion day is the end of the exam period.
Please read this before answering the following question
Is this child listed on a current Medicare card?
98
To receive Family Tax Benefit Part A supplement, immunisation
requirements will need to be met for the financial years
during which a child turns 1, 2 or 5 years of age.
For a list of acceptable evidence of your child meeting the
immunisation requirements, see Immunisation Details in the
Information Booklet.
To do this you need to provide details of the current Medicare
card the child is listed on so that we can confirm this childs
immunisation is up-to-date, or that they have an approved
exemption.
Please read this before answering the following question
No
Yes
Go to next question
Childs Medicare reference number (if applicable)
Reference
Number
First given name and second initial
Number on the current Medicare card
For example, exemption from study.
99 Was this child under 4 years of age on 30 June 2014?
No
Yes Go to 107
Go to next question
FA048.1407
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Child 4
Do you have legal or other documents to support the change of
care?
No
Yes
Go to next question
Attach a copy of this document.
No
Yes
Did this child come into your care from someone else during
the 20132014 financial year?
108
Go to 112
Who cared for this child before you?
Name
Address
Postcode
Contact phone number (if known)
( )
When did this child enter your care? 109
/ /
What periods in 20132014 did this child live with you?
From
/ / / /
/ /
/ /
/ /
110
111
To
/ /
/ /
/ /
No
Yes
Did this child receive any of the following payments or
education allowances during the 20132014 financial year?
Go to next question
Go to 106
Carer Payment
Community Development Employment Projects (CDEP)
Participant Supplement
Disability Support Pension
Disability Support Pension (Blind)
Parenting Payment
Sickness Allowance
Special Benet
Youth Allowance
Veterans' Children Education Scheme (VCES)/Military
Rehabilitation and Compensation Act Education and
Training Scheme (MRCAETS) paid by the Department of
Veterans' Affairs.
Was this child 16 years or over and had a partner during the
20132014 financial year?
$
No
Yes What was their combined adjusted taxable income?
Go to next question
103
104
Do you have a child support care determination for this child? 107
No
Yes
No
Yes
Was this childs adjusted taxable income $14,078 or more in
the 20132014 financial year?
Give details below
Go to next question
102
If this childs income for the 20132014 financial year was
$14,078 or more you are not entitled to receive family
assistance for them for that part of the 20132014 financial
year where the child income rules apply.
For more information, see Eligible child in the Information
Booklet.
$
Did this child receive ABSTUDY (do not include Schooling A)
during the 20132014 financial year?
106
No
Yes
Certain allowances can be received in addition to Family Tax
Benefit.
Did this child receive payment(s) for the entire 20132014
financial year?
105
No
Yes This child is not an eligible Family Tax Benefit child
do not answer any more questions for THIS child.
Go to next question
Go to 137
FA048.1407
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Child 4
Please read this before answering the following question
To receive your correct entitlement of Family Tax Benefit you
should confirm your percentage of care with the other person
caring for this child.
For more information, see Shared care in the Information
Booklet.
What percentage of care did you have of this child during the
20132014 financial year?
%
Provide the periods of shared care for this child during the
20132014 financial year
If there are more dates, attach a separate sheet with details.
From To
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
OR
How many nights was this child in your care during the
20132014 financial year?
From To
/ / / /
116
117
Did you have a parenting plan, court order or written agreement
for the period during the 20132014 financial year?
No
Yes
Go to 116
Attach a copy of the parenting plan, court
order or written agreement.
Did this child spend time in care with someone else other than
you (and/or your partner at 30 June 2014) such as their other
parent if you were separated, grandparent or other carer
during the 20132014 financial year (e.g. weekends, school
holidays)?
To be paid any Family Tax Benefit, you must have care of this
child for at least 35 per cent of the time during the
20132014 financial year. To be considered in your care, you
must be responsible (whether jointly or with someone else)
for their day-to-day care, welfare and development. A child
living independently is an example of someone who may not
qualify as an eligible child.
For more information, see Shared care in the Information
Booklet.
Who did this child spend time with?
No
Yes
Postcode
Name
Address
Go to 121
112
113
No
Yes
Was the parenting plan, court order or written agreement
complied with during the 20132014 financial year?
114
Was the shared care arrangement for this child for the full
20132014 financial year?
Go to 117
No
Yes
Go to next question
115
Go to 116
Go to next question
FA048.1407
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Child 4
Did this child leave your care for MORE than a short period
during the 20132014 financial year?
A short period is generally a period less than 4 consecutive
weeks. To be considered in your care, you must be
responsible (whether jointly or with someone else) for their
day-to-day care, welfare and development. A child living
independently is an example of someone who may not qualify
as an eligible child.
Provide the periods during which this child was not in
your care
No
Yes
Was this with your consent?
No
Yes
Did you take reasonable action to regain care of this child?
No
Yes
Did this child die during the 20132014 financial year?
If a child died, you may be eligible to receive a bereavement
payment.
No
Yes
/ /
Date of death
We will contact you to provide more information.
If there are more dates, attach a separate sheet with details.
From To
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
/ / / /
Go to 121
Go to next question
Go to 121
Go to next question
Please read this before answering the following question
If any dependent child in your care is from a previous
relationship, you are required to take reasonable action to
obtain a child support assessment in order to receive more
than the base rate of Family Tax Benefit Part A.
For more information, see Children from a previous
relationship in the Information Booklet.
The following questions are about child support you (and/or
your partner at 30 June 2014) were entitled to receive and
actually received during the 20132014 financial year.
Is this child from a previous relationship?
No
Yes
Go to next question
Go to 124
Did you (and/or your partner) take any action to obtain a child
support assessment for this child (e.g. by contacting Child
Support services) during the 20132014 financial year?
No
Yes
Please explain why you (and/or your partner) did not take any
action to obtain a child support assessment for this child. Please
include details, if there is any reason that makes it difficult for
you (and/or your partner) to apply for a child support assessment.
Action taken by:
You
Your partner
Go to next question
Go to 127
119
120
121
118 122
125
126
Go to 131
Did you (and/or your partner) receive or were you (and/or your
partner) entitled to receive any child support for this child during
the 20132014 financial year?
No
Go to next question
Go to 135
Yes
123
Did you (and/or your partner) have a current child support
assessment for this child during the 20132014 financial year?
No Go to next question
Yes
124
If you had a child support assessment, details will
be obtained directly from Child Support services.
Your claim will remain pending until this information
is received electronically from Child Support services.
Go to 127
FA048.1407
46 of 58
Child 4
From whom were you (and/or your partner) entitled to receive
child support for this child during the 20132014 financial year?
Full name(s)
127
The details of the child support action you (and/or your
partner) have taken for this child will be obtained directly
from Child Support services. Your claim will remain pending
until this information is received from Child Support services.
Child support can include cash, capitalised maintenance/
lump sum payment(s) and non-cash amounts. Non-cash child
support includes receiving food, clothes etc from the other
parent, and also includes payment(s) made to another person
or organisation on your behalf, such as loan repayments,
school fees, rates, insurance, household expenses, child care
fees, school fees or other expenses/purchases. Non-cash
amounts must be reported as a dollar value. Capitalised
maintenance or a lump sum payment is maintenance that is
not a regular or a periodic payment and is worth more than
$1,500. It may be provided as a lump sum payment (i.e. a
cash amount) or a property settlement (i.e. your home, a car,
a business etc).
For more information see the Information Booklet.
Please read this before answering the following questions 128
Did you (and/or your partner) receive any child support for this
child that was not part of a child support assessment (i.e. you
received more than the child support assessed amount) for any
period you were Child Support services collect during the
20132014 financial year?
No
Yes
Go to next question
Did you receive any voluntary child support for this child during
the 20132014 financial year?
131
$
No
Yes
Go to 135
How much was received
Go to 134
Did you (and/or your partner) discharge any child support
arrears during the 20132014 financial year?
133
No
Yes
Go to next question
What was the amount of arrears you discharged?
$
/ /
On what date did you discharge the arrears?
Discharged child support arrears
If you changed from Child Support services collect to private
collect and you had child support owing to you, you may have
elected to discharge any amount owed to you from the Child
Support services collect period. You must tell us if you have
discharged arrears, or you later discharge arrears.
For more information, see Children from a previous
relationship in the Information Booklet.
Please read this before answering the following questions 132
Did you (and/or your partner), change from Child Support
services collect to private collect, at any time during the
20132014 financial year?
No
Yes
Go to 134
Go to next question
Did you (and/or your partner) receive any additional child
support for this child that was not part of a child support
assessment (i.e. you received more than the child support
assessed amount) for any period you were private collect during
the 20132014 financial year?
129
You will need to tell Child Support services if you
received any additional child support (including
cash, a lump sum payment or non cash).
Go to next question
No
Yes
Go to 132
Go to next question
Did this amount include any child support arrears that were
owed to you for a private collect period before 1 July 2012?
130
No
Yes
Go to 132
What was the total additional child support received
for this child during the 20132014 financial year?
$
Child support arrears relate to a child support amount owed
to you when you were a private collect customer, and you
privately collected an amount that was less than your child
support assessment.
Please read this before answering the following question
Go to 132
FA048.1407
Did you (and/or your partner) receive any child support in
relation to this child having a disability or learning difficulty
during the 20132014 financial year?
No
Yes
Go to next question
How much was received:
$
Through Child Support services
$
Privately
47 of 58
Child 4
134
135
Apart from Family Tax Benefit, there are other payments or
assistance that families may be entitled to receive.
Please read this before answering the following questions
Is this child an orphan? 136
No
Yes
Go to next question
Does this child have a disability?
No
Yes
Go online www.humanservices.gov.au/carers for
more information about Carer Allowance and/or
Carer Payment.
Go to next question
For more information and our definition of an orphan, see
Double Orphan Pension in the Information Booklet.
Did you have another child, during the 20132014 financial year,
for whom you wish to claim a lump sum payment of Family Tax
Benefit?
No
Yes
Go to 138 on page 48
137
Go to next question on the next page
FA048.1407
48 of 58
Did you receive any payments from the Department of Veterans
Affairs in the 20132014 financial year?
Go to next question No
Yes Give details below
Type of payment
Department of Veterans Affairs reference number
138
Have you lodged a tax return for the 20132014 financial
year?
Go to 141 No
Yes Go to next question
If you need to lodge a tax return for the 20132014 nancial
year and have not done so, we cannot assess your Family Tax
Benet until your taxable income details are conrmed by the
Australian Taxation Ofce. To check if you are required to lodge
a tax return, go to the Australian Taxation Office website www.
ato.gov.au
Why will you not be lodging a tax return for the
20132014 financial year?
No
Yes
$
Go to 143
Has this payment stopped?
No
Yes When did this payment stop
Did your partner receive any payments from the Department of
Veterans Affairs in the 20132014 financial year?
Go to next question No
Yes Give details below
Please read this before answering the following questions 139
Have you received your Taxation Notice of Assessment? 140
Go to 142 No
Yes What was your taxable income on your Taxation Notice
of Assessment?
Will you lodge a tax return for the 20132014 financial year? 141
Has your partner lodged a tax return for the 20132014 financial
year?
Go to 141 No
Yes Go to next question
If your partner needs to lodge a tax return for the 20132014
nancial year and have not done so, we cannot assess your
Family Tax Benet until their taxable income details are
conrmed by the Australian Taxation Ofce. To check if your
partner is required to lodge a tax return, go to the Australian
Taxation Office website www.ato.gov.au
Why will they not be lodging a tax return for the
20132014 financial year?
No
Yes
$
Go to 143
Please read this before answering the following questions
Has your partner received their Taxation Notice of Assessment?
Go to 142 No
Yes What was their taxable income on their Taxation Notice
of Assessment?
Will your partner lodge a tax return for the 20132014 financial year?
You Your partner on 30 June 2014
/ /
Go to next question Go to next question
Service Pension
Income Support Supplement
Age Pension
Other Give details below
/ /
Fortnightly amount
When did you start to receive
this payment
$
Type of payment
Department of Veterans Affairs reference number
Has this payment stopped?
No
Yes When did this payment stop
/ /
Service Pension
Income Support Supplement
Age Pension
Other Give details below
/ /
Fortnightly amount
When did your partner start to
receive this payment
$
138
139
140
141
FA048.1407
49 of 58
Use the following table to estimate your (and/or your partners) taxable income for 1 July 2013 to 30 June 2014.
Note: If you did not receive income from any of the following sources, please write $0 in the appropriate boxes.
142
143
A Estimated taxable income from salary and wages
B Estimated taxable income from lump sum payment(s)
C Estimated taxable income from business or self-employment
D Estimated taxable income from investments
E Estimated taxable income from real estate
F Estimated taxable income from government pensions or benefits
G Other estimated taxable income
Total estimated taxable income (total of A to G)
Profit
or
Loss
=
$
You Your partner
$
$ $
Profit
or
Loss
$ $
$ $
$ $
$ $
$ $
AUD AUD
$ $
Profit
or
Loss
$ $
$ $
For more information, see Estimating your actual annual family income in the Information Booklet.
B Reportable superannuation contributions
C Total net investment losses
E Foreign income
Provide details of how much you (and/or your partner) expect to receive from any of the following sources in the 20132014 financial year.
Note: If you do not receive income from any of the following sources, please write $0 in the appropriate boxes.
A Reportable fringe benefits
Estimated amount
G Child support PAID
You
$
Estimated amount
$
Estimated amount
$
Estimated amount
AUD
Estimated amount
$
Estimated amount
Your partner
$
Estimated amount
$
Estimated amount
$
Estimated amount
AUD
Estimated amount
$
F Tax exempt foreign income
Estimated amount
AUD
Estimated amount
AUD
D Tax free pensions and benefits
Estimated amount
$
Estimated amount
$
For more information, see Providing an income estimate in the Information Booklet.
FA048.1407
Go to next question
You are not entitled to this extra assistance.
What date did you cease previous employment?
No
Yes
Did you commence or return to work for the FIRST time after
the birth of a baby or after a period out of the workforce to care
for a child who came into your care?
145
146
Go to 156
50 of 58
For more information, see Parents returning to work in the
Information Booklet.
Did you have a partner at any time during the 20132014
financial year?
No
Single parents do not need to apply for this extra
assistance.
Go to next question Yes
Returning to work
144
Go to 156
You Your partner on 30 June 2014
Go to next question
Your partner is not entitled to this extra assistance.
What date did your partner cease previous employment?
No
Yes
Did your partner commence or return to work for the FIRST time
after the birth of a baby or after a period out of the workforce
to care for a child who came into your care?
Go to 156
Never worked
Previously worked Date ceased work
/ /
Never worked
Previously worked Date ceased work
/ /
Date you commenced this work
Since returning to work, did you work an average of at least
10 hours per week over a period of 4 consecutive weeks?
No Go to next question
147
Yes
/ /
Date your partner commenced this work
Since returning to work, did your partner work an average of at
least 10 hours per week over a period of 4 consecutive weeks?
No Go to next question
Yes
/ /
Go to 151 Go to 151
Since returning to work, did you work less than 10 hours per
week?
Go to next question
148
No
Yes
Go to 150
Since returning to work, did your partner work less than 10 hours
per week?
Go to next question
No
Yes
Go to 150
Do you wish to nominate that you have returned to work?
No
Go to next question Yes
149
You should contact us if you decide at a later date
that you would like to nominate a return to work.
Go to 156
Does your partner wish to nominate that they have returned to
work?
No
Go to next question Yes
Your partner should contact us if they decide at a
later date that they would like to nominate a return
to work.
Go to 156
Did you return to work in the 20132014 financial year? 150
Date you commenced work
No Go to 153
Yes
/ /
Did your partner return to work in the 20132014 financial year?
Date your partner commenced work
No Go to 153
Yes
/ /
145
146
147
148
149
150
FA048.1407
This includes annual leave, paid maternity leave, long service
leave or sick leave periods for which you were paid since you
stopped work, or paid to you in advance of stopping work. This
also includes payments you received in the previous financial
year if paid in respect of a period that includes the financial
year you commenced or returned to work.
If you do not have this information, you may need to contact
your employer to confirm any periods of paid leave.
Did you have any periods of paid leave during the financial year
in which you commenced or returned to work?
Go to next question
Give details below for each leave type
153
No
Yes
This includes annual leave, paid maternity leave, long service
leave or sick leave periods for which your partner was paid
since they stopped work, that was paid to them in advance of
them stopping work. This also includes payments they received
in the previous financial year if paid in respect of a period that
includes the financial year they commenced or returned to work.
If your partner does not have this information, they may need
to contact their employer to confirm any periods of paid leave.
Did your partner have any periods of paid leave during the financial
year in which your partner commenced or returned to work?
Period start date Period end date
If more space is required, attach a separate sheet with details.
Type of leave entitlement
1
/ / / /
Period start date Period end date
Type of leave entitlement
2
/ / / /
Period start date Period end date
If more space is required, attach a separate sheet with details.
Type of leave entitlement
1
/ / / /
Period start date Period end date
Type of leave entitlement
2
/ / / /
Go to next question
Give details below for each leave type
No
Yes
51 of 58
You Your partner on 30 June 2014
Was the return to work related to starting or recommencing
self-employment?
151
No
Yes
Was the return to work related to starting or recommencing
self-employment?
No
Yes
Provide details of employer or self-employment
Address (if not your home)
Name of employer
Contact phone number
Postcode
Australian Business Number (ABN)
152
( )
Provide details of employer or self-employment
Address (if not your home)
Name of employer
Contact phone number
Postcode
Australian Business Number (ABN)
( )
153
151
152
You can obtain your employers correct Australian Business
Number (ABN) from your payslips, payment summary, tax
return advice or by contacting your employer.
You can obtain your partners employers correct Australian
Business Number (ABN) from your partners payslips,
payment summary, tax return advice or by contacting your
partners employer.
FA048.1407
52 of 58
Did you have any periods of work related insurance or
compensation during the financial year in which you commenced
or returned to work?
This includes payments you received in the previous financial
year that were paid in respect of a period that includes the
financial year you commenced or returned to work.
Give details below of the periods for each work related
insurance or workers compensation payment
154 Did your partner have any periods of work related insurance or
compensation during the financial year in which they
commenced or returned to work?
This includes payments your partner received in the previous
financial year that were paid in respect of a period that
includes the financial year they commenced or returned to work.
Give details below of the periods for each work related
insurance or workers compensation payment
You Your partner on 30 June 2014
Go to next question No
Yes
Go to next question No
Yes
Period start date Period end date
If more space is required, attach a separate sheet with details.
Type of payment
1
/ / / /
Period start date Period end date
Type of payment
2
/ / / /
Period start date Period end date
If more space is required, attach a separate sheet with details.
Type of payment
1
/ / / /
Period start date Period end date
Type of payment
2
/ / / /
154
155
This is intended to cover periods of income derived from your
continued right to receive income (such as a share of the
profits) from your previous self-employment (involving a
substantial degree of exertion) in a business, partnership or
other entity.
You may be asked to provide evidence of the information you
have provided in relation to your previous employment or
return to work.
After ceasing ACTIVE involvement in self-employment, have you
had any periods of income from self-employment received during
the financial year in which you commenced or returned to work?
Give details below of the periods during which you have
received income from self-employment
This is intended to cover periods of income derived from your
partners continued right to receive income (such as a share
of the profits) from your partners previous self-employment
(involving a substantial degree of exertion) in a business,
partnership or other entity.
Your partner may be asked to provide evidence of the
information they have provided in relation to their previous
employment or return to work.
After ceasing ACTIVE involvement in self-employment, has your
partner had any periods of income from self-employment received
during the financial year in which your partner commenced or
returned to work?
Give details below of the periods during which your
partner has received income from self-employment
Go to next question No
Yes
Go to next question No
Yes
If more space is required, attach a separate sheet with details.
Period start date Period end date
/ / / /
/ / / /
/ / / /
/ / / /
If more space is required, attach a separate sheet with details.
Period start date Period end date
/ / / /
/ / / /
/ / / /
/ / / /
155
FA048.1407
53 of 58
Did you receive any private spousal maintenance in the
20132014 financial year?
156
Go to next question
No
Yes
Go to 159
What was the total amount of private spousal maintenance you
received in the 20132014 financial year?
157
$
You Your partner on 30 June 2014
Did your partner receive any private spousal maintenance in the
20132014 financial year?
Go to next question
No
Yes
Go to 159
What was the total amount of private spousal maintenance your
partner received in the 20132014 financial year?
$
From whom did you receive private spousal maintenance during
the 20132014 financial year?
158 From whom did your partner receive private spousal
maintenance during the 20132014 financial year?
Full name
If you received or were entitled to receive private spousal
maintenance from more than one payer copy page 53 covering
questions 156 to 158.
Full name
If your partner received or was entitled to receive private
spousal maintenance from more than one payer copy page 53
covering questions 156 to 158.
156
157
158
Please read this before answering the following questions Please read this before answering the following questions
During the 20132014 financial year, were you in a relationship
with someone other than the partner you had on 30 June 2014?
No
Yes
Do not answer questions 160 to 176.
Go to 177
Please read this before answering the following questions
To help calculate your lump sum payment, we need you to
provide details of any partners you had during the 20132014
financial year, other than your partner on 30 June 2014. These
partners are called previous partner(s).
Previous partners
159
The following questions will ask you about 2
previous partners. If you had more than 2 previous
partners in the 20132014 financial year, attach
a separate sheet with details.
Go to next question
FA048.1407
54 of 58
This previous partners country of birth
This previous partners date of birth
This previous partners current home address (if known)
This previous partners sex
Has this previous 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)?
If this previous partner has more than 2 other names, attach a
separate sheet with details.
161
Other
Family name
First given name
Second given name
Ms Miss Mrs Mr
Name of previous partner 1 160
Details of PREVIOUS PARTNER 1
in the 20132014 financial year
Details of PREVIOUS PARTNER 2
in the 20132014 financial year
Has this previous 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)?
Other
Family name
First given name
Second given name
Ms Miss Mrs Mr
Name of previous partner 2
162
163
164
165
This previous partners country of birth
This previous partners date of birth
This previous partners current home address (if known)
This previous partners sex
Go to next question
Other name
Type of name (e.g. name at birth)
Give details below
1
No
Yes
Other name
Type of name (e.g. maiden name)
2
Go to next question
Other name
Type of name (e.g. name at birth)
Give details below
1
No
Yes
Other name
Type of name (e.g. maiden name)
2
If this previous partner has more than 2 other names, attach a
separate sheet with details.
Male
Female
/ /
Male
Female
/ /
Postcode Postcode
161
160
162
163
164
165
FA048.1407
Periods of your relationship with this previous partner during the
20132014 financial year
Go to 169
Go to next question Not sure
Yes
Go to next question No
Not knowing your previous partners tax file number
will not affect your payment.
This previous partners tax file number
No
Yes
Do you know this partners tax file number?
Has this previous partner given us their tax file number before?
To help calculate your lump sum payment, you must provide
income details for this previous partner you had during the
20132014 financial year.
If you cannot provide exact details, you must estimate as
best you can.
Use question 142 of this form as a guide to calculate their total
estimated income
Please read this before answering the following question
What was this previous partners total estimated taxable income
for the 20132014 financial year?
If the total amount is zero, write $0
Did this previous partner have any reportable superannuation
contributions in the 20132014 financial year?
Did this previous partner receive any reportable fringe benefits
in the 20132014 financial year?
No
Yes Estimated amount
166
167
168
169
55 of 58
Periods of your relationship with this previous partner during the
20132014 financial year
Go to 169
Go to next question Not sure
Yes
Go to next question No
Not knowing your previous partners tax file number
will not affect your payment.
This previous partners tax file number
No
Yes
Do you know this partners tax file number?
Has this previous partner given us their tax file number before?
To help calculate your lump sum payment, you must provide
income details for this previous partner you had during the
20132014 financial year.
If you cannot provide exact details, you must estimate as
best you can.
Use question 142 of this form as a guide to calculate their total
estimated income
Please read this before answering the following question
What was this previous partners total estimated taxable income
for the 20132014 financial year?
If the total amount is zero, write $0
170
171 Did this previous partner have any reportable superannuation
contributions in the 20132014 financial year?
Did this previous partner receive any reportable fringe benefits
in the 20132014 financial year?
Details of PREVIOUS PARTNER 1
in the 20132014 financial year
Details of PREVIOUS PARTNER 2
in the 20132014 financial year
From To
/ / / /
/ / / /
/ / / /
From To
/ / / /
/ / / /
/ / / /
$ $
$
Go to next question No
Yes Estimated amount
$
Go to next question
No
Yes Estimated amount
$
Go to next question No
Yes Estimated amount
$
Go to next question
166
167
168
169
170
171
FA048.1407
Did this previous partner receive any tax free pensions or benefits
in the 20132014 financial year?
Did this previous partner receive any foreign income in the
20132014 financial year?
Did this previous partner PAY child support in the 20132014
financial year?
173
174
176
Did this previous partner receive any tax free pensions or benefits
in the 20132014 financial year?
Did this previous partner receive any foreign income in the
20132014 financial year?
Did this previous partner PAY child support in the 20132014
financial year?
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Details of PREVIOUS PARTNER 1
in the 20132014 financial year
Details of PREVIOUS PARTNER 2
in the 20132014 financial year
No
Yes Estimated amount
$
Go to next question No
Yes Estimated amount
$
Go to next question
No
Yes Estimated amount
AUD
Go to next question No
Yes Estimated amount
AUD
Go to next question
No
Yes Estimated amount
$
Go to next question No
Yes Estimated amount
$
Go to next question
Did this previous partner receive any tax exempt foreign income
in the 20132014 financial year?
175 Did this previous partner receive any tax exempt foreign income
in the 20132014 financial year?
No
Yes Estimated amount
AUD
Go to next question No
Yes Estimated amount
AUD
Go to next question
Did this previous partner have any net investment losses in the
20132014 financial year?
172 Did this previous partner have any net investment losses in the
20132014 financial year?
No
Yes Estimated amount
$
Go to next question No
Yes Estimated amount
$
Go to next question
173
174
176
175
172
FA048.1407
Please read this before answering the following question
Which of the following forms, documents and other attachments are you providing with this form?
57 of 58
177
Document checklist
At certain questions on this form, you may have been asked to attach documents.
In the following list, tick the box next to each document you are providing. Please provide original documentation.
The documents will be returned to you by registered post or you can have them photocopied at one of our Service Centres.
You
Australian residence
Other attachments
Citizenship papers, passport or other documentation
(if you answered No at question 24)
Child details (if not previously provided to Human Services for family assistance
payments) See questions 67 137 Tick one box for each child
Other government issued document
Child 1
You
Child 2
Your
partner
Adoption papers
Child 3 Child 4
Birth certificate or extract
Authorising a person or organisation to enquire or act on your behalf form (SS313)
(if you answered Yes at question 5)
Full copy of current lease or tenancy agreement
(if you answered Yes at question 62)
Claim for Paid Parental Leave and Family Assistance form (FA100)
(if you answered Yes at question 38)
If a child came into your care from someone else during the 20132014 financial year
A copy of legal or other documents supporting the change of care (e.g. parenting plan,
court order or written agreement) (if you answered Yes at question 111)
If you shared the care of a child with a person other than your current partner
A copy of the parenting plan, court order or written agreement
(if you answered Yes at question 113)
Continue to next page
FA048.1407
Your signature
Date
I declare that:
the information I have provided in this form is complete and
correct.
I understand that:
giving false or misleading information is a serious offence.
the Australian Government Department of Human Services
may work out my lump sum payment based on my and my
partners estimated income and that if the actual annual
family income is different any overpayment will need to be
paid back.
some or all of an overpayment may be recovered from my tax
refund and/or future Family Tax Benefit payments, including
supplement payments.
Family Tax Benefit including supplement payments can be
used to offset a tax debt or used to repay Family Tax Benefit
or Child Care Benefit or Child Care Rebate overpayments from
other years.
the Australian Government Department of Human Services
can make relevant enquiries to make sure I receive my correct
entitlement.
Statement
Your partners (on 30 June 2014) signature (if applicable)
Date
179
/ /
/ /
Statement
58 of 58
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.
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 about the way in which the
Department of Human Services will manage your personal
information, including our privacy policy at www.
humanservices.gov.au/privacy or by requesting a copy from
the department.
178 IMPORTANT INFORMATION
FA048.1407

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