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 3 of 58 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 4 of 58 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 6 of 58 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 7 of 58 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 8 of 58 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 9 of 58 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 FA048.1407 10 of 58 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 FA048.1407 11 of 58 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 12 of 58 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 14 of 58 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 43 of 58 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 44 of 58 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 45 of 58 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? 56 of 58 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