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Application for an Form

Offshore Humanitarian visa


Refugee and Humanitarian (Class XB) visa
842
Department of Home Affairs

The Department of Home Affairs (the Department) About this form


acknowledges that Aboriginal and Torres Strait Islander peoples
Important – Please read this information carefully before you
are the traditional custodians of the Australian land.
complete your application. When you have completed your
application we recommend that you keep a copy for your
Life in Australia – Australian values records.
The Australian Government encourages people to gain an
understanding of Australia, its people and their way of life, Australia’s offshore humanitarian Program
before applying for a visa to live in Australia. There are a limited number of places available each year under
This includes understanding that the English language, as the the program. In setting the size of the program, the Australian
national language, is an important unifying element of Government considers:
Australian society. Australian society is also united through • the views of the United Nations High Commissioner for
the following shared values: Refugees (UNHCR);
• respect for the freedom and dignity of the individual; • the views of the Australian community; and
• freedom of religion; • Australia’s capacity to settle refugees and people in need.
• commitment to the rule of law;
• Parliamentary democracy; Requirements for each visa subclass
• equality of men and women; Your application will be assessed against the 5 visa subclasses of
• a spirit of egalitarianism that embraces mutual respect, the Refugee and Humanitarian (Class XB) visa class. To be
tolerance, fair play and compassion for those in need and granted a visa, you must be assessed as meeting the
pursuit of the public good; requirements for one of these subclasses. These are set out in
• equality of opportunity for individuals, regardless of their Australia’s Migration Act and Regulations and the main
race, religion or ethnic background. requirements for each subclass are:
The Life in Australia booklet provides more information on Refugee (subclass 200)
the values that Australians share and their way of life. This
• You are living outside your home country; and
booklet is available in a wide range of languages. If you have
not already received a copy then it can be obtained from • you are subject to persecution in your home country; and
www.homeaffairs.gov.au • you are in need of resettlement.
You must read the Life in Australia booklet before The UNHCR provides advice to the Australian Government on
completing this application form. If you have difficulty, or are the need for resettlement.
unable to read the booklet, you may have the content of it
explained to you, for example, by a friend or relative. This In-country Special Humanitarian (subclass 201)
form contains a statement, that you must sign, that confirms • You are in your home country; and
you understand and will respect the values of Australian • you are subject to persecution.
society (as explained in the booklet) and will obey the laws
Only a small number of places are available under this subclass.
of Australia. This includes acknowledging what would be
required if you later applied for Australian citizenship. Global Special Humanitarian (subclass 202)
This statement must also be signed by each person aged • You are living outside your home country; and
18 years or over, who is included in this form.
• you are subject to substantial discrimination amounting to
gross violation of your human rights in your home country;
and
Who should use this application?
• you have included a valid form 681 Refugee and Special
You should use this form if you are outside Australia and wish to
Humanitarian Proposal with your application.
apply for entry to Australia on humanitarian grounds. This class
of visa includes the following 5 subclasses: Form 681 needs to be completed by an Australian citizen or
permanent resident, eligible New Zealand citizen, or community
• Refugee (subclass 200)
organisation in Australia (a ‘proposer’) who is willing to support
• In-country Special Humanitarian (subclass 201) your application.
• Global Special Humanitarian (subclass 202) As the government does not fund travel costs for this visa
• Emergency Rescue (subclass 203) subclass, your proposer is expected to assist you and any
• Woman at Risk (subclass 204). dependants in meeting costs associated with travel to Australia
and initial settlement after arrival.
You should also use this form if you are applying for one of the
above visas in the Community Support Program. Emergency Rescue (subclass 203)
• You are subject to persecution in your home country; and
• there are urgent and compelling reasons for you to be
resettled in Australia.
Requests for urgent assistance under this subclass are usually
made on your behalf by the UNHCR.
© COMMONWEALTH OF AUSTRALIA, 2018 842 (Design date 02/18) - Page 1
Woman at Risk (subclass 204) To be eligible for the grant of a humanitarian visa under the ‘split
• You are a woman living outside your home country; and family’ provisions for immediate family:
• subject to persecution in your home country or are registered • you must apply within 5 years of the permanent Protection,
with the UNHCR as being ‘of concern’; and permanent humanitarian or Resolution of Status visa being
granted to your proposer;
• without the protection of a male relative; and
• your proposer must complete a form 681 Refugee and
• in danger of victimisation, harassment or serious abuse Special Humanitarian Proposal (available from offices of the
because you are female. Department in Australia or the Home Affairs website) for you
Children under 18 to submit together with your own visa application;
Children under the age of 18 who have no parents, or who have • your proposer must have declared you to the Department as
been separated from their parents, may also be granted a visa in an immediate family member before the grant of their own
one of the subclasses listed above. However, the Australian visa.
Government must be satisfied the child’s entry to Australia is in
the best interest of the child and that the rights of the parents, if Partner
any, are properly considered. ‘Partner’ means your spouse or de facto partner (including
If any children under 18 who are members of the family unit and same-sex partners).
included in this application are not your biological children, you
must provide information and documentation as to who their Residential address
birth parents are/were.
You must advise the Department where you intend to live while
your application is being dealt with, or if you change your
Community Support Program residential address after your application has been lodged.
The Community Support Program enables communities and Failure to give a residential address will result in your application
businesses, as well as families and individuals, to propose being invalid. A post office box address will not be accepted as
applicants with employment prospects (and their families) and to your residential address.
support their settlement in Australia. Only Approved Proposing
Organisations (APOs) may propose people for entry to Australia Your application
in the Community Support Program.
You should answer the questions in this form truthfully and fully
Information about the Community Support Program is available and attach any supporting documents. Forms that are incomplete
from the Department’s website www.homeaffairs.gov.au/CSP could delay a decision being made on your application, or your
Note: Your APO must complete form 1417 Community Support application could be refused.
Program Proposal by Approved Proposing Organisation. Your Not all applicants are interviewed and a decision may be taken on
APO must lodge both of these forms (form 842 and form 1417) the information provided in your application only. You need to
electronically, by post or by courier at the Department’s Special make sure you include all details about your situation in your
Humanitarian Processing Centre in Sydney. application.
The Department will share your personal information that was If you need more space than is provided in this form for any of
collected during the processing of your application with your your answers, attach a separate page, clearly marking the
APO. If a visa is granted, this information may be used by the APO question number the page relates to. Additional pages must be
to enable delivery of settlement services and support. Your APO signed and dated by each person aged 18 years or over included
may also share your personal information with other in this application.
organisations, known as Supporting Community Organisations,
so they can provide services to you to help you settle in Australia.
Who should be included in this application?
You should include in this form ALL members of your family unit.
‘Split family’ provisions for immediate family of permanent Your family unit includes your spouse, de facto partner (including
Protection (Class XA), permanent humanitarian same-sex partner), dependent children outside Australia and
(Class XB) or Resolution of Status (Class CD) visa holders. other dependent relatives who usually live with you (eg. a
You should use this form if, within the last 5 years, a member of dependent parent). ‘Dependent’ means wholly or substantially
your ‘immediate family’ was granted either a: dependent on you or your partner for financial, psychological or
physical support.
• permanent Protection visa (subclass 866); or
Details of dependent family members NOT included in your visa
• permanent humanitarian visa (subclasses 200, 201, 202, 203 application should be included at Question 12. If you fail to
or 204); or declare immediate family members in your application, they may
• Resolution of Status (Class CD) visa (subclass 851). not be able to access the ‘split family’ provisions for immediate
Note: Your proposer must not have been an illegal maritime family members (referred to above) if they apply for a visa at a
arrival who arrived on or after 13 August 2012. later time.
Note: Under the ‘split family’ provisions, ‘Immediate family’ Non-dependent family members (eg. married children or
means you are the spouse, de facto partner (including children over 18 who are independent) should complete their
same-sex partner), dependent child or in certain own form 842 if they wish to be considered for entry to Australia
circumstances a parent of the person in Australia who is on humanitarian grounds.
proposing your entry (that is, your proposer has completed
form 681). Integrity of application
Note: You can only apply as a parent under these ‘split family’ The Department is committed to maintaining the integrity of the
provisions if your child in Australia is under 18 years of age. visa and citizenship programs. Please be aware that if you provide
us with fraudulent documents or claims, this may result in
processing delays or your application being refused.

842 (Design date 02/18) - Page 2 © COMMONWEALTH OF AUSTRALIA, 2018


What documents should you attach to this application? Change of circumstances
Two (2) passport-sized photographs of each person included in If your circumstances change in any way after you have lodged
the application, that have the name of the person written on the this form (eg. you or a family member enters into a new
back. relationship, becomes engaged, or marries), you must inform the
office where the application was lodged. If a child is born to
Supporting documents you (or any other person included in this application)
The documents you must provide are requested throughout this after the application is lodged, the child will be included
form. There is also a document checklist in Part Q of this form in your application if details are provided before a final
and you should carefully check you have provided all the listed decision is made on your application.
documents.
You should also provide all documents necessary to support Processing information
your humanitarian claims. You should be aware that there is strong interest in this class of
Copies of documents must be certified as true copies of the visa and it may take a long time to finalise your application.
original by a Justice of the Peace, Commissioner for Declarations, You may need to have a medical and an x-ray examination as part
or a person before whom a Statutory Declaration may be made of the assessment of your application. You may also be asked to
under the Statutory Declarations Act 1959. Outside Australia, a undergo medical treatment as part of the assessment of the visa
person who is equivalent to a Justice of the Peace or a application. The Australian Government reserves the right to
Commissioner for Declarations must certify copies. conduct character checks on all adult applicants. Details of your
If you do not provide all the necessary documents, a application are not passed on to your home country.
decision may be made on the information you have The Australian Government will pay the costs related to medical
provided. It is in your interest to support your examinations for all humanitarian visa applicants, except visa
application with as much information as possible at the applicants in the Community Support Program. All visa
time of application. subclasses, except Global Special Humanitarian (subclass 202)
If you are not able to provide any of the documents listed visa holders and visa holders in the Community Support
at Part Q, please provide a written explanation why the Program, will also have their travel costs paid by the Australian
documents are not available. Government.
Under no circumstances should you submit false
documents. Important information about privacy
Your personal information is protected by law, including the
Where can you lodge this application? Privacy Act 1988. Important information about the collection,
Applicants wishing to be considered for a Class XB visa in the use and disclosure (to other agencies and third parties, including
Refugee category must lodge their form at an Australian overseas overseas entities) of your personal information, including
mission. For addresses, please see the Department’s website sensitive information, is contained in form 1442i Privacy notice.
www.homeaffairs.gov.au/about/contact/offices-locations Form 1442i is available from the Department’s website
www.homeaffairs.gov.au/allforms/ or offices of the
Electronic lodgement is available to applicants wishing to be
Department. You should ensure that you read and understand
considered for a Class XB visa under the Global Special
form 1442i before completing this form.
Humanitarian Program (subclass 202), including the ‘split family’
provisions for immediate family members and the Community The Department is careful to protect the privacy of all applicants.
Support Program. Care will be taken to make sure that details of your application
do not reach your home country.
For further information, please see the information sheet Lodging
Certain Humanitarian Applications in Australia available from
the Department’s website Review rights
www.homeaffairs.gov.au/trav/refu/offs/lodging-certain- If your application is refused, it is not possible to obtain a review
humanitarian-applications-in-australia of the decision by the Administrative Appeals Tribunal.

Is there an application or processing charge? Settlement services


Applicants in the Community Support Program must pay a Visa If you are granted a humanitarian visa (subclasses 200, 201, 202,
Application Charge. Please refer to the Visa Pricing Table 203 or 204), information on the personal possessions that you
www.homeaffairs.gov.au/trav/visa/fees may take with you to Australia is available from the office that
Other applicants do not pay a charge to lodge this application. granted your visa.
The Australian Government provides a range of services to help
Is there a charge for the form? refugee and humanitarian entrants settle in Australia. This
assistance may include being met on arrival by a service provider
No – forms 681, 842 and 1417 are free and may be obtained from
and taken to accommodation, help to register for income
any office of the Department in Australia and overseas or from
support, help to arrange medical appointments, information
the Department’s website www.homeaffairs.gov.au/allforms/
about your new community, and attending English language
classes.
Interviews and requests for more information Note: If you are granted a humanitarian visa in the Community
Interviews are not always necessary. We will advise you if you are Support Program, settlement services will be provided to you by
required to attend an interview or if you need to provide more your APO, in conjunction with any Supporting Community
documents or information. Organisation.

© COMMONWEALTH OF AUSTRALIA, 2018 842 (Design date 02/18) - Page 3


Immigration assistance Appointing a migration agent/exempt person
A person gives immigration assistance to you if he or she uses, or To appoint a migration agent/exempt person you should complete
claims to use, his or her knowledge or experience in migration Part M – Options for receiving written communications.
procedure to assist you with your visa application, request for Your migration agent/exempt person should complete form 956
ministerial intervention, cancellation review application, Advice by a migration agent/exempt person of providing
sponsorship or nomination. immigration assistance.
In Australia a person may only lawfully give immigration Form 956 is available from the Department’s website
assistance if he or she is a registered migration agent or is exempt www.homeaffairs.gov.au/allforms/
from being registered. Only registered migration agents may
receive a fee or reward for providing immigration assistance. Options for receiving written communications
If an unregistered person in Australia, who is not exempt from If you do not appoint a migration agent/exempt person you may
registration, gives you immigration assistance they are still authorise another person, in writing, to receive written
committing a criminal offence and may be prosecuted. communications on your behalf. This person is called the
Restrictions on giving immigration assistance, charging fees for authorised recipient.
immigration assistance and restrictions on charging fees for
immigration representations apply even where the APO lodges Authorised recipient information
form 842 (this form) on behalf of a client in the Community All written communication about your application will be sent to
Support Program. your authorised recipient, unless you indicate that you wish to
have health and/or character information sent directly to you. If
Migration agents in Australia your visa application is subject to proposal form 681 or form 1417
Migration agents in Australia must be registered with the Office and you wish all communication to be sent to your proposer, you
of the Migration Agents Registration Authority (Office of the will need to complete Question 18 and Question 47 on this form.
MARA) unless they are exempt from registration. The Department will communicate with the most recently
Migration agents outside Australia appointed authorised recipient as you may only appoint one
authorised recipient at any time for a particular application.
Migration agents who operate outside Australia do not have to be
registered. The Department may give some overseas agents an You will be taken to have received any documents sent to that
ID number. This number does not mean that they are registered. person as if they had been sent to you.
Note: Some Australian registered migration agents operate
overseas. Consent to communicate by email
The Department may use a range of means to communicate with
Migration agent information you. However, email will only be used if you indicate your
A migration agent is someone who can: agreement to receiving communication in this way.
• advise you on the visa that may best suit you; To process your application the Department may need to
• tell you the documents you need to submit with your communicate with you about sensitive information, for example,
application; health, police checks, financial viability and personal
relationships. Emails, unless adequately encrypted, are not
• help you fill in the application and submit it; and secure and may be viewed by others or interfered with.
• communicate with the Department on your behalf. If you agree to the Department communicating with you by
If you appoint a migration agent, the Department will assume email, the details you provide will only be used by the
that your migration agent will be your authorised recipient, Department for the purpose for which you have provided them,
unless you indicate otherwise. unless there is a legal obligation or necessity to use them for
Your migration agent will be the person with whom the another purpose, or you have consented to use for another
Department will discuss your application and from whom it will purpose. They will not be added to any mailing list.
seek further information when required. The Australian Government accepts no responsibility for the
You are not required to use a migration agent. However, if you security or integrity of any information sent to the Department
use a migration agent, the Department encourages you to use a over the internet or by other electronic means.
registered migration agent. Registered agents are bound by the If you authorise another person to receive documents on your
Migration Agents Code of Conduct, which requires them to act behalf and they wish to be contacted electronically, their
professionally in their clients’ lawful best interests. signature is required on form 956 or 956A to indicate their
Information on migration agents, including a list of registered consent to this form of communication.
migration agents, is available on the Office of the MARA website Note: Email is the fastest means of communication available and
www.mara.gov.au the Department prefers to communicate by email because this
You can also access information about migration agents on the results in faster processing.
Department’s website www.homeaffairs.gov.au

Exempt persons Home page www.homeaffairs.gov.au


The following people do not have to be a registered migration
agent in order to provide immigration assistance, but they must General Telephone 131 881 during business hours
not charge a fee for their service: enquiry line in Australia to speak to an operator (recorded
• a close family member (spouse, de facto partner, child, parent, information available outside these hours).
brother or sister); If you are outside Australia, please contact
your nearest Australian mission.
• a member of parliament or their staff;
• an official whose duties include providing immigration
assistance (eg. a Legal Aid provider);
• a member of a diplomatic mission, consular post or
international organisation.
Please keep these information pages for your reference
842 (Design date 02/18) - Page 4 © COMMONWEALTH OF AUSTRALIA, 2018
Application for an Form

Offshore Humanitarian visa


Refugee and Humanitarian (Class XB) visa
842
Department of Home Affairs

Please open this form using Adobe Acrobat Reader.


Either type (in English) in the fields provided or print this form and complete it (in English) using a pen and BLOCK LETTERS.
PHOTOGRAPH
Please attach two (2)
Tick where applicable recent passport sized
photographs of yourself
Part A – Summary of people included in this application AND
• Only include members of your family who are dependent on you or your partner. all members of your
• A dependant is a person who is wholly or substantially dependent on you or your partner for financial, psychological or family unit included in this
physical support. application
Note: Clearly write the
• The term ‘partner’ in this form, means your spouse or de facto partner (including same-sex partners).
name of the person on the
• Non-dependent family members (eg. adult independent children, married children or children over 18 who have their back of each photograph
own income) should complete their own application form. However you should still list any non-dependent children at
Question 14 and Question 15 of Part D on this form.
• You must attach evidence of the identity of each person (eg. certified copy of birth certificate, marriage certificate,
passport), wherever this is available. If you do not have identity documents, please attach an explanation as to why you
no longer have them.
• For each person included who is not the main applicant’s partner or child under 18 years, you must attach a statement
explaining why this person is dependent on the main applicant.
• It is important that all names are spelled correctly and dates of birth are accurate.

1 How many people are included in this application? 4 Relationship status


Married legally Engaged Widowed
2 Give details of the main applicant Married by De facto Never married or
tradition/custom been in a de facto
Family name MOGHIMI A1 Separated
relationship
Married religiously Divorced
Given names MASOUD
For your relationship status (other than ‘never married or been in a
Name in own de facto relationship’), give the following details:
language or Day Month Year
ethnic script Date this happened 07/08/2007
Sex Male Female
Day Month Year
Place this happened SHIRAZ, IRAN

Date of birth 01/07/1982 Your previous name (if applicable)

Place of birth Town/city AHWAZ


Do you currently have more than one partner (other than any partner
Country IRAN included in this visa application)?
No
Citizenship IRANIAN
Yes Please provide details
If stateless, write your previous country of citizenship
Current country of INDONESIA
residence
Day Month Year
Date you arrived in 03/06/2013
this country
Select
Status in this country R See below for codes to be used
If you have indicated you are ‘never married or been in a de facto
relationship’ or ‘engaged to be married’, are you currently in any other
form of a relationship (eg. boyfriend/girlfriend)?
‘Status in this country’ codes
No
C = Citizen
PR = Permanent resident Yes Please provide details
TR = Temporary resident
S = Student
V = Visitor/Tourist
R = Refugee
I = Illegal resident
A = Asylum/protection applicant
O = Other – give details on a separate page

© COMMONWEALTH OF AUSTRALIA, 2018 842 (Design date 02/18) - Page 5


3 Give details of all other people included in this application
1. Family name SAEDI A2 2. Family name MOGHIMI A3

Given names KHADIJEH Given names HANI


Name in own Name in own
language or language or
ethnic script ethnic script
Sex Male Female Sex Male Female
Day Month Year Day Month Year

Date of birth 15/08/1982 Date of birth 27/04/2009

Place of birth Town/city TEHRAN Place of birth Town/city AHWAZ

Country IRAN Country IRAN

Citizenship IRANIAN Citizenship IRANIAN


If stateless, write your previous country of citizenship If stateless, write your previous country of citizenship
Relationship status Relationship status
Married legally Engaged Widowed Married legally Engaged Widowed
Married by De facto Never married or Married by De facto Never married or
tradition/custom Separated been in a de facto tradition/custom Separated been in a de facto
relationship relationship
Married religiously Divorced Married religiously Divorced
Relationship to Relationship to SON
main applicant WIFE main applicant
Is this person biologically related to the main applicant? Is this person biologically related to the main applicant?
No Explain how they are related to the main applicant No Explain how they are related to the main applicant

Yes Describe the precise biological relationship Yes Describe the precise biological relationship
COUSIN SON

842 (Design date 02/18) - Page 6 © COMMONWEALTH OF AUSTRALIA, 2018


3. Family name MOGHIMI A4 4. Family name A5

Given names OMAR Given names


Name in own Name in own
language or language or
ethnic script ethnic script
Sex Male Female Sex Male Female
Day Month Year Day Month Year

Date of birth 19/02/2016 Date of birth

Place of birth Town/city JAKARTA Place of birth Town/city

Country INDONESIA Country

Citizenship STATELESS Citizenship


If stateless, write your previous country of citizenship If stateless, write your previous country of citizenship
Relationship status Relationship status
Married legally Engaged Widowed Married legally Engaged Widowed
Married by De facto Never married or Married by De facto Never married or
tradition/custom Separated been in a de facto tradition/custom Separated been in a de facto
relationship relationship
Married religiously Divorced Married religiously Divorced
Relationship to SON Relationship to
main applicant main applicant
Is this person biologically related to the main applicant? Is this person biologically related to the main applicant?
No Explain how they are related to the main applicant No Explain how they are related to the main applicant

Yes Describe the precise biological relationship Yes Describe the precise biological relationship
SON

© COMMONWEALTH OF AUSTRALIA, 2018 842 (Design date 02/18) - Page 7


5. Family name A6 6. Family name A7

Given names Given names


Name in own Name in own
language or language or
ethnic script ethnic script
Sex Male Female Sex Male Female
Day Month Year Day Month Year

Date of birth Date of birth

Place of birth Town/city Place of birth Town/city

Country Country

Citizenship Citizenship
If stateless, write your previous country of citizenship If stateless, write your previous country of citizenship
Relationship status Relationship status
Married legally Engaged Widowed Married legally Engaged Widowed
Married by De facto Never married or Married by De facto Never married or
tradition/custom Separated been in a de facto tradition/custom Separated been in a de facto
relationship relationship
Married religiously Divorced Married religiously Divorced
Relationship to Relationship to
main applicant main applicant
Is this person biologically related to the main applicant? Is this person biologically related to the main applicant?
No Explain how they are related to the main applicant No Explain how they are related to the main applicant

Yes Describe the precise biological relationship Yes Describe the precise biological relationship

If you need more space, please attach a separate page with the details
Attach evidence of identity of each person included in this application
(eg. certified copies of birth certificates, marriage certificates,
passport, national identity card)

842 (Design date 02/18) - Page 8 © COMMONWEALTH OF AUSTRALIA, 2018


Part B – Applicants mandated or registered by UNHCR
4 Has any person included in this application been mandated as a refugee or
registered with the United Nations High Commissioner for Refugees (UNHCR)?
No
Yes Give details
Name Refugee Mandate number(s) Country of mandate
MASOUD MOGHIMI 186-13C04872 INDONESIA
KHADIJEH SAEDI 186-13C04872 INDONESIA
HANI MOGHIMI 186-13C04872 INDONESIA
OMAR MOGHIMI 186-13C04872 INDONESIA

Name Refugee Registration number(s) Country of registration

Attach a certified copy of evidence of your refugee status/registration

Part C – Contact details


5 Your residential address (not postal address) 8 Do you agree to the Department communicating with you by email?
Note: You must tell us if your address changes after you lodge this form. No
GADING MEDITERANIA RESIDENCE.JL.BUKIT Yes Provide at least one primary and any secondary email
addresses you can be contacted on
GADING MEDITERANIA. RT.6/RW.14/KIP.GADING
Primary MASOUDMOGHIMI61@JMAIL.CO
BAR KUTA JAKARTA ULTARA Postal code 1440
Secondary RASHED.MOGHIMI@YAHOO.CO
6 Your postal address
Secondary dawoodi.hanan@YAHOO.COM
(If the same as your residential address, write ‘AS ABOVE’)
Note: If you wish to nominate a person other than yourself to receive
AS ABOVE
written communications about this application, you must indicate this
at Part M.
Postal code

7 Your contact telephone numbers (if available)


Country code Area code Number
Telephone ( 0062 ) ( 021 ) 081260000926
number
Mobile/cell 081286066654

© COMMONWEALTH OF AUSTRALIA, 2018 842 (Design date 02/18) - Page 9


Part D – Family background 3. Family name

9 Have you or any other person included in this visa application Given names
previously been legally married, in a de facto relationship or in a Previous partner’s full name
customary/traditional/religious marriage that is not legally recognised?
No
Day Month Year
Yes Give details of each person below
Dates of
Note: Include partners who you are divorced or separated relationship From
from or who are missing or deceased.
To
1. Family name How did the relationship end?

Given names
Previous partner’s full name Names of all children from this previous relationship

Day Month Year


Dates of
relationship From

To If you need more space, please attach a separate page with the details
How did the relationship end? Attach a certified copy of previous marriage/divorce documents or
death certificate (if applicable/available)

Names of all children from this previous relationship 10 Do you or any other person included in this application have children
from a previous marriage/relationship, including customary/traditional
marriage?
No
Yes Do they have sole custody of any children under 18 years of
age who are included in this application?

2. Family name No Yes Attach a certified copy of the


custody documents (if available)
Given names Note: Where custody documents are not provided or
assessed as unsatisfactory, the former partner will need to
Previous partner’s full name
provide evidence that he/she consents to any children of
that relationship entering Australia.
Day Month Year
Dates of
relationship From

To
How did the relationship end?

Names of all children from this previous relationship

842 (Design date 02/18) - Page 10 © COMMONWEALTH OF AUSTRALIA, 2018


11 Are there any children included in this application who are not the 3. Family name
biological children of either you (the main applicant) or your partner?
No Given names
Yes Give details of each child Day Month Year

Date of birth
1. Family name
Relationship
Given names to you
Full name of biological father
Day Month Year

Date of birth
Relationship Full name of biological mother
to you
Full name of biological father
Whereabouts of biological parents
(if deceased or unknown, please state)
Full name of biological mother

Whereabouts of biological parents


(if deceased or unknown, please state)
Has this child been adopted (formally, customarily or traditionally)
by the main applicant and/or partner?
No
Yes Date custody commenced
Day Month Year
Has this child been adopted (formally, customarily or traditionally)
by the main applicant and/or partner?
No If you need more space, please attach a separate page with the details
Yes Date custody commenced For each adopted child, attach a certified copy of the adoption
Day Month Year
papers (if available) or attach a statement which explains the
circumstances of the adoption

2. Family name

Given names
Day Month Year

Date of birth
Relationship
to you
Full name of biological father

Full name of biological mother

Whereabouts of biological parents


(if deceased or unknown, please state)

Has this child been adopted (formally, customarily or traditionally)


by the main applicant and/or partner?
No
Yes Date custody commenced
Day Month Year

© COMMONWEALTH OF AUSTRALIA, 2018 842 (Design date 02/18) - Page 11


12 Do you have a husband, wife, de facto partner or any dependants who 13 Is any person included in this application physically separated from you
normally live with you but who are not included in this application? (eg. missing or living at a separate address/location)?
A dependant is a person who is wholly or substantially dependent on No
you or your partner for financial, psychological or physical support. Yes Give details and explain when and where you were last
No in contact with them
Yes Give details and explain why they do not intend to migrate
with you as part of this visa application 1. Family name

1. Family name Given names


Day Month Year
Given names Date of birth
Day Month Year
Relationship
Date of birth to you
Relationship Last contact (when, where and how you were separated)
to you
Reason they are not applying with you

Full residential address (if known)

Postal code
2. Family name

Given names
2. Family name
Day Month Year

Date of birth Given names


Day Month Year
Relationship
to you Date of birth
Reason they are not applying with you Relationship
to you
Last contact (when, where and how you were separated)

3. Family name Full residential address (if known)

Given names
Day Month Year

Date of birth Postal code

Relationship
to you 3. Family name
Reason they are not applying with you
Given names
Day Month Year

Date of birth
Relationship
to you
If you need more space, please attach a separate page with the details
Last contact (when, where and how you were separated)

Full residential address (if known)

Postal code

If you need more space, please attach a separate page with the details

842 (Design date 02/18) - Page 12 © COMMONWEALTH OF AUSTRALIA, 2018


14 Relatives of MAIN APPLICANT
Give details of ALL YOUR parents, brothers and sisters and non-dependent children. You must include half, step and adopted relatives.
If any person listed below is not biologically related to you, you must clearly indicate this.
Note: You must list ALL relatives, whether they are living, deceased, or their whereabouts are unknown. If any relative is deceased or
missing/whereabouts unknown, then you must write ‘DECEASED’ or ‘UNKNOWN’ in the ‘Country where they are now living’ column.
Relationship Status in ‘Relationship status’ codes
Relationship
Sex Date of birth to main Country where they country of N = Never married or been in a
Name status Place and country of birth applicant are now living residence de facto relationship
(use codes
on right) (use codes (use codes M = Married legally
M/F Day Month Year on right) on right) E = Engaged to be married
Your parents Select Select Select S = Separated
F = In a de facto relationship
ZOHRAB MOGHIMI M 22/05/1960 M AHVAZ, IRAN PB IRAN C D = Divorced
MASOUMEH SAEDI F 31/01/1959 M ABADAN,IRAN PB IRAN C W = Widowed
MT = Married by tradition/custom
Mother’s maiden name MR = Married religiously
MASOUMEH
‘Relationship to main applicant’
Your brothers and sisters Select Select Select codes
PB = Parent – Biological
AHMAD MOGHIMI M 14/08/1984 M AHVAZ,IRAN SB AUSTRALIA TR PA = Parent – Adoptive
SOAD MOGHIMI F 03/08/1986 M AHVAZ,IRAN SB IRAN C PS = Parent – Step
PO = Parent – Other
HOSIN MOGHIMI M 22/03/1988 M AHVAZ,IRAN SB IRAN C (attach explanation)
SB = Sibling – Biological (full)
MOHAMAD MOGHIMI M 11/09/1992 N AHVAZ,IRAN SB IRAN C
SA = Sibling – Adoptive
MORTEZA MOGHIMI F 14/05/1999 N AHVAZ,IRAN SB IRAN C SS = Sibling – Step
SO = Sibling – Other
(attach explanation)
CB = Child – Biological
CA = Child – Adoptive
CS = Child – Step
CO = Child – Other
(attach explanation)

‘Status in country of residence’


Your non-dependent children (all children who are not included as dependants in this application) Select Select codes
C = Citizen
PR = Permanent resident
TR = Temporary resident
S = Student
V = Visitor/Tourist
R = Refugee
I = Illegal resident
A = Asylum/protection applicant
O = Other – give details on a
separate page

If you need more space, please attach a separate page listing further names
© COMMONWEALTH OF AUSTRALIA, 2018 842 (Design date 02/18) - Page 13
15 Relatives of main applicant’s PARTNER
Give details of ALL YOUR PARTNER’s parents, brothers and sisters and non-dependent children, including children your partner has had with other partners.
You must include half, step and adopted relatives. If any person listed below is not biologically related to your partner, you must clearly indicate this.
Note: You must list ALL YOUR PARTNER’s relatives, whether they are living, deceased, or their whereabouts are unknown. If any relative is deceased or
missing/whereabouts unknown, then you must write ‘DECEASED’ or ‘UNKNOWN’ in the ‘Country where they are now living’ column.
Relationship Status in ‘Relationship status’ codes
Relationship
Sex Date of birth to main Country where they country of N = Never married or been in a
Name status Place and country of birth applicant are now living residence de facto relationship
(use codes
on right) (use codes (use codes M = Married legally
M/F Day Month Year on right) on right)
E = Engaged to be married
Your partner’s parents Select Select Select S = Separated
F = In a de facto relationship
ABDOLKHADER SAEDI M 13/07/1955 M IRAN PB PASS AWAY C D = Divorced
SEDIGHEH DASHTEBAN F 10/12/1963 M IRAN PB IRAN C W = Widowed
MT = Married by tradition/custom
Your partner’s mother’s maiden name MR = Married religiously
SEDIGHEH
‘Relationship to main applicant’
Your partner’s brothers and sisters Select Select Select codes
PB = Parent – Biological
AREZO SAEDI F 21/07/1981 M TEHRAN,IRAN SB IRAN C PA = Parent – Adoptive
SAEDEH SAEDI F 28/10/1985 N TEHRAN,IRAN SB IRAN C PS = Parent – Step
PO = Parent – Other
SAED SAEDI M 1/021987 M SHIRAZ,IRAN SB IRAN C (attach explanation)
SB = Sibling – Biological (full)
SA = Sibling – Adoptive
SS = Sibling – Step
SO = Sibling – Other
(attach explanation)
CB = Child – Biological
CA = Child – Adoptive
CS = Child – Step
CO = Child – Other
(attach explanation)

‘Status in country of residence’


Your partner’s non-dependent children (all children who are not included as dependants in this application) Select Select codes
C = Citizen
PR = Permanent resident
TR = Temporary resident
S = Student
V = Visitor/Tourist
R = Refugee
I = Illegal resident
A = Asylum/protection applicant
O = Other – give details on a
separate page

If you need more space, please attach a separate page listing further names
842 (Design date 02/18) - Page 14 © COMMONWEALTH OF AUSTRALIA, 2018
Part E – Links to Australia
16 Has any person included in this application ever applied for an Australian visa (permanent or temporary) before?
No
Yes Give details

Family and given name


Date of application File number Application approved?
(If all persons included in this application, Where was the application lodged?
(if known)
write ‘All’) Day Month Year No Yes Not decided

If you need more space, please attach a separate page with the details

17 Do you or your partner have any relatives NOT INCLUDED IN THIS VISA APPLICATION who have current Australian visa applications under consideration?
No
Yes Give details

Date of application File number Type of visa application


Family and given name Where was the application lodged?
Day Month Year (if known) (if known)

If you need more space, please attach a separate page with the details

18 Is any person included in this application being proposed (on form 681 or form 1417) for entry to Australia by a person or organisation in Australia?
No
Yes Give details of your proposer or Approved Proposing Organisation (in case of a Community Support Program application)
Family name SEATON

Given names ASHLEY JOHN


OR
Organisation name

Contact person

Relationship of the
proposer to you FRIEND AND COLLEAGUE THROUGH CHURCH W

Telephone number (Area code +61 ) +61478921295

Note: Proposers in the Global Special Humanitarian (subclass 202) program must complete form 681 Refugee and Special Humanitarian
Proposal and lodge both form 681 and this form (form 842) together. There is no charge for lodging or processing form 681.
Note: APOs under the Community Support Program must complete form 1417 Community Support Program Proposal by Approved Proposing
Organisation and lodge both form 1417 and this form (form 842) together. For charges associated with lodging and processing form 1417, refer
to the Visa Pricing Table www.homeaffairs.gov.au/trav/visa/fees
These forms are available from the Department’s website www.homeaffairs.gov.au

© COMMONWEALTH OF AUSTRALIA, 2018 842 (Design date 02/18) - Page 15


19 ‘Split family’ provisions for ‘immediate family’ members
Are any people included in this application members of the immediate family of a person in Australia who, in the last 5 years,
was granted a Refugee/Humanitarian visa outside Australia, or a Protection or Resolution of Status (Class CD) visa inside Australia?
‘Immediate family’ means a spouse or de facto partner (including same-sex partner), dependent children,
or parent (if your child in Australia is under 18 years of age)
No
Yes Give details of the immediate family member who was granted the visa
Family name

Given names

File number (if known)


Name of the person in this
application they are related to
Relationship

Where did they last live together?


Day Month Year

When did they last live together?

How did they become separated?

Attach a completed form 681 Refugee and Special Humanitarian Proposal to this application (there is no charge
for lodging or processing form 681)
Your proposer should complete form 681 for lodgement with this visa application. Form 681 is available from
any office of the Department, or from the Department’s website www.homeaffairs.gov.au
Attach a certified copy of the immediate family member’s Australian visa label or visa grant letter and evidence
of the relationship (eg. marriage certificate, birth certificate) if available
Provide details of humanitarian claims at Part G, Questions 25 – 37

842 (Design date 02/18) - Page 16 © COMMONWEALTH OF AUSTRALIA, 2018


20 Do any people included in this application have any other relatives residing in Australia?
No
Yes Give details Select
Details of the relative in Australia Details of the person in this application they are related to
Residence
Date of birth status in
Name Australia Address Given names Relationship to applicant
(use codes
Day Month Year below)

1. Ahmad Moghimi 14 /08/1984 TR 6 Parer way RoxburghPark 3064 vic Ahmad Brother

2. Hanan Davoudi 28/12/1990 TR 6 Parer way RoxburghPark 3064 vic Hanan Brother’s wife

3. Ghazal Moghimi 31/08/2009 TR 6 Parer way RoxburghPark 3064 vic Ghazal Nephew

4. Amjad Moghimi 27/01/2014 TR 6 Parer way RoxburghPark 3064 vic Amjad Nephew

5.

If you need more space, please attach a separate page with the details

21 Do any people included in this application have any other past or present links to Australia?
No
Yes Indicate the types of links and give details
Links: Education Employment Business Friend Other

Details

‘Residence status in Australia’ codes


C = Citizen
PR = Permanent resident
TR = Temporary resident
S = Student
V = Visitor/Tourist
I = Illegal resident
U = Unlawful non-citizen
O = Other – give details on a separate page

© COMMONWEALTH OF AUSTRALIA, 2018 842 (Design date 02/18) - Page 17


Part F – Background information A3 Given names HANI MOGHIMI
Does this person have a travel or identity document?
22 Give details of any valid travel documents (eg. passports) or identity
cards/documents held by all people included in this application No Attach a statement explaining what happened
to your documents
Note: If you do not have any documents, please explain why – do not
obtain fraudulent documents. Yes Give details
Select
Type of document P
(use codes below)
A1 Main applicant
Passport number 26877414
Do you have a travel or identity document? (or document number)

No Attach a statement explaining what happened Country of issue IRAN


to your documents
Day Month Year
Yes Give details
Select Date of issue 20/05/2013
Type of document P
(use codes below) Date of expiry 20/05/2018
Passport number 26875205
(or document number) Issuing authority/place of issue as shown in passport (or other document)
Country of issue IRAN
Day Month Year

Date of issue 19/05/2013


A4 Given names OMAR MOGHIMI
Date of expiry 19/05/2018
Does this person have a travel or identity document?
Issuing authority/place of issue as shown in passport (or other document)
No Attach a statement explaining what happened
to your documents
Yes Give details
Select
Type of document UN
Other applicants (use codes below)
Passport number
A2 Given names KHADIJEH SAEDI (or document number)
186-13C04872

Does this person have a travel or identity document? Country of issue INDONESIA
No Attach a statement explaining what happened Day Month Year
to your documents
Date of issue
Yes Give details
Select
Type of document Date of expiry
P
(use codes below)
Issuing authority/place of issue as shown in passport (or other document)
Passport number 26875444
(or document number)

Country of issue IRAN


Day Month Year

Date of issue 19/05/2013 A5 Given names

Date of expiry 19/05/2018 Does this person have a travel or identity document?
No Attach a statement explaining what happened
Issuing authority/place of issue as shown in passport (or other document)
to your documents
Yes Give details
Select
Type of document
(use codes below)
Passport number
(or document number)

Country of issue
Day Month Year

Date of issue

Date of expiry
Issuing authority/place of issue as shown in passport (or other document)
‘Type of document’ codes
P = Passport
UN = UN Convention travel document or Titre de voyage
A = Alien/Asylum Registration Card
CI = Certificate or document of identity
S = Seafarer identity document
NIC = National identity card

842 (Design date 02/18) - Page 18 © COMMONWEALTH OF AUSTRALIA, 2018


A6 Given names

Does this person have a travel or identity document?


No Attach a statement explaining what happened
to your documents
Yes Give details
Select
Type of document
(use codes below)
Passport number
(or document number)

Country of issue
Day Month Year

Date of issue

Date of expiry
Issuing authority/place of issue as shown in passport (or other document)

A7 Given names

Does this person have a travel or identity document?


No Attach a statement explaining what happened
to your documents
Yes Give details
Select
Type of document
(use codes below)
Passport number
(or document number)

Country of issue
Day Month Year

Date of issue

Date of expiry
Issuing authority/place of issue as shown in passport (or other document)

If you need more space, please attach a separate page with the details
Attach certified copies of the travel documents and identity
documents, if available

‘Type of document’ codes


P = Passport
UN = UN Convention travel document or Titre de voyage
A = Alien/Asylum Registration Card
CI = Certificate or document of identity
S = Seafarer identity document
NIC = National identity card

© COMMONWEALTH OF AUSTRALIA, 2018 842 (Design date 02/18) - Page 19


23 Has any person included in this application applied to migrate to another country, or applied for refugee resettlement or asylum in any country?
No
Yes Give details

Family and given names Type of application


Date of application Application approved?
(If all persons included in this application, Which country? (eg. refugee resettlement,
write ‘ALL’) Day Month Year migration, asylum etc.) No Yes Not decided

If you need more space, please attach a separate page with the details

24 For EACH person included in this application list every address where they have lived during the last 10 years
Date you started to live
Given names of people included in this application
Address where you are living now at this address
who live at this address (if all, write ‘ALL’)
Day Month Year

KAUTHAR RESIDENTIAL COMPLEX,SHAHID 01/05/2009 MASOUD MOGHIMI


AZADI STREET KOYE SADI ,AHWAZ KHADIJEH SAEDI
HANI MOGHIMI
Town AHWAZ Country IRAN

Period at this address Given names of people included in this application


Previous addresses
Month Year who live at this address (if all, write ‘ALL’)
1. LLIA RESIDENTIAL COMPLEX, LADAN 3 From 05/2011 MASOUD MOGHIMI
STREET AHWAZ To 05/2013 KHADIJEH SAEDI
HANI MOGHIMI
Town AHWAZ Country IRAN

2. TOWER SANTA MONIKA ,KELAPA GADING From 07/2013 MASOUD MOGHIMI


MOI JAKARTA UTARA To 01/2014 KHADIJEH SAEDI
HANI MOGHIMI
Town Jakarta Country Indonesia

3. PERUMAHAN PUSPA GADING ,KELAPA From 10/2014 ALL


GADING JAKARTA UTARA To 10/2016

Town JAKARTA Country INDONESIA

4. APARTMENT GADING MEDITERANIA From 10/ 2016 ALL


RESIDENCE,TOWER A KELAPA GADING To NOW
JAKARTA UTARA
Town JAKARTA Country INDONESIA

5. From

To

Town Country

Attach certified copies of any visas/residence permits held by your family

842 (Design date 02/18) - Page 20 © COMMONWEALTH OF AUSTRALIA, 2018


Part G – Humanitarian claims
• Your application will be assessed against the following 4 factors:
– the degree of persecution or discrimination to which you are subject in your home country
– the extent of your connection with Australia
– whether or not there is any suitable country available, other than Australia, that can provide for your settlement and protection from discrimination
– the capacity of the Australian community, or in the case of a Community Support Program application, your Approved Proposing Organisation, to
provide for the permanent settlement of persons such as you in Australia.
All applicants should include as much information as possible about these factors.
• Not all applicants are interviewed.
• Your answers should pay special attention to what happened to you and your family, not to the general situation in the country you fear returning to.
• When answering, you should tell us everything about why you and your family think you should be considered for entry to Australia under the Humanitarian
Program.
• In answering these questions, you should tell us if you think any incidents you mention are because of:
– your race
– your religion
– your nationality
– your membership of a particular social group
– your political opinion
– other reasons.
• You should provide as much information as possible relating to dates, locations, etc in respect of any incidents you mention.

25 For ALL the people included in this application list the ethnic group to which they belong, their religion and any political party/group to which they belong
Membership of political party/group
Given names Ethnic group or clan Religion (if any)
(if any)

A1 Main applicant ARAB CHRISTIAN ADPF

Other applicants
A2 KHADIJEH SAEDI PERSIAN CHRISTIAN

A3 HANI MOGHIMI CHRISTIAN

A4 OMAR MOGHIMI CHRISTIAN

A5

A6

A7

If you need more space, please attach a separate page with the details
© COMMONWEALTH OF AUSTRALIA, 2018 842 (Design date 02/18) - Page 21
26 What is the name of the country you fear living in or returning to?
IRAN

27 Have you left the country you fear living in?


No
Yes Date you left
Day Month Year
03/06/2013

28 Why do you fear living in or returning to the country you listed at Question 26?
Your answer should pay special attention to what happened to you, not the general situation in that country.
I believe that my family and I will be in great danger if we return to Iran, because My political activities as an Ahwazi
mean that if we returned, we would be in great danger.
After Iran’s revolution in 1978, minority groups including Arab tribes were not allowed to freely practice cultural
traditions or speak Arabic.
I consider these to be basic human rights and so I have spoken out about this as an Arab in Iran, in particular in Ahwaz.
I have fought for our right to speak our mother tongue (which is Arabic for official duties), the right to wear our
traditional clothing in public, and the right of freedom to vote. Currently, Arabs in Iran are not allowed these rights. In
Ahwaz, I ran a mobile phone shop at Golestan Boulevard 30, opposite Chamran University in Ahwaz. My business
cards were in Arabic as well as Persian, my shop featured Arabic decorations and I wore Arabic clothing. One day, a
customer of mine named Haj Mohamad Sobhani, who was chief of staff of Khuzestan province police, warned me that I
should remove the Arabic writing on my business cards, remove the Arabic decorations from my shop and stop wearing
Arabic clothing or I would face serious trouble. I had already seen Arabic shopkeepers forced by the government to
close their businesses because of the false belief that these shopkeepers were somehow a threat to national security.
The government often falsely accused these people of being rebels against the state. The warning I received made me
more determined to speak out against the oppression, cruelty and injustice carried out by the Iranian regime against
minority groups like Ahwazi.
I joined the Ahwazi Democratic Popular Front and produced some videos and reports on the oppression faced by the
Ahwazi for the Jebhe of Democratic Mardomi Ahwaz’s website in the hope that they would highlight our suffering for the
rest of the world and show how we have been oppressed by the Iranian authoritarian regime. I also began teaching
Arabic to young Arabic Ahwazi who were afraid of learning it in case they were bullied or punished by the government.

This continued until January 2013 when my family was woken from sleep by a knock at the door of our home at Ilia
Complex, Moin Zade alley, Ladan 3 Street, Ahwaz at around 5.30am. Upon answering the door I saw around eight
people, who asked my name and showed me a seizure warrant which they did not let me read. They searched my
home, finding and confiscating three books (one about Sunni religion ,another about Khuzestan’s history, and an Arabic
language dictionary.) They also confiscated a broken PC. They then took me from my home by force. They blindfolded
me and refused to say where they were taking me, instead saying “We have some questions that we want to ask
you.”When we arrived at this unknown destination I was still blindfolded. When they finally removed the blindfold they
forced me to sign a paper that called for me to behave well in detention. They then moved me to a small room, roughly
2m x 3m, and held me there for 17 days. On the 18th day they took me to Kianpars Inqilab court, alleging that I was a
member of the rebel group Ahwazi Democratic Popular Front (ADPF) and had made and spread propaganda against
the Iranian government. This is a common allegation made by the Iranian regime towards Ahwazis. I denied the
allegations for fear of being harmed and was released on bail after my father’s brother paid 1,050,000,000 Rials. He
supplied his house’s certificate to ensure my release. Two days after my release, two friends of mine named Adel Atabi
and Said Cheldavi, who had helped me broadcast some of my announcements via social media, were arrested by the
authorities.
When this happened I met with my friend Javad Treiry, who is a lawyer (+98916 311 6702). He advised that I should
have freedom of movement while on bail but that there was no guarantee and it was possible that I could be
interrogated by the government if I tried to travel via the airport. This was a problem for me as I often needed to travel
to Dubai to buy mobiles to sell in my store and I was worried that if I did not have freedom to travel I would not be able
to continue my livelihood successfully. Following my arrest I also felt very insecure about simply living in Iran, so I
decided to leave with my family and my younger brother, Ahmad. I put my trust in God and luckily we were able to
leave the country from Shiraz airport on Monday second of jun2013 We flew to Qatar and then Jakarta, Indonesia,
arriving on 3rd June 2013.
My experience of being persecuted, having my family home ransacked, being abducted and detained and then taken to
court means that I am very fearful of returning to Iran because I could face more of the same or even worse. The safety
of my family is very important and it is for this reason that we cannot return.

If you need more space, please attach a separate page with the details

842 (Design date 02/18) - Page 22 © COMMONWEALTH OF AUSTRALIA, 2018


29 If you have left the country you fear, how did you leave?
Legally Give details of your exit permit
Ahwaz,SHIRAZ,IRAN- DOHA, QATAR-JAKARTA, INDONESIA
Illegally Describe how you arranged to leave illegally

30 What do you believe may happen to you, or the people included in your application, if you were to return to or continue living in that country?
You should give full details of what you think may happen to you and reasons why that would happen
I am absolutely certain that harm would come to us. Our experience before we fled Iran was enough to tell me that we

were already in grave danger due to our religious and political beliefs. I believe that if I returned to Iran, I would again

be abducted and jailed. I could be tortured, my family could also be hurt. I also believe that there is a very strong

chance that our lives would actually be at risk and we could be murdered. My family and I are deeply distressed at the

thought of this and so we absolutely cannot return under any circumstances. My wife and children mean everything to

me and I would never knowingly put them in such danger. We are terrified that if we are made to return to Iran, we will

be harmed or killed.

If you need more space, please attach a separate page with the details

31 Who do you think may harm or mistreat you if you continue living in or go back to that country?
It is widely known and accepted that the Iranian government has been capturing and secretly executing Ahwazi Arab

activists, and this is supported by an April 2015 Amnesty International report. The treatment that my family and I

received before we fled Iran indicates that the Iranian authoritarian regime was already taking steps to harm us. There

is no doubt in my mind that if we returned to Iran, the government would not protect us but would instead go out of its to

way do us great harm.

If you need more space, please attach a separate page with the details
© COMMONWEALTH OF AUSTRALIA, 2018 842 (Design date 02/18) - Page 23
32 Do you think the authorities of that country can and will protect you if you continue living in or return to that country?
No Please explain why
Yes BECAUSE OUR PROBLEM IS WITH GOVERNMENT

33 Did you travel through, or stay, in any other countries before arriving in the country where you are now living?
No
Yes Give details including length of stay and dates
Date
Country From To
Day Month Year Day Month Year

United Arab Emirates


Turkey

34 Has this application been lodged because the United Nations High Commissioner for Refugees (UNHCR) referred you to Australia for resettlement?
No
Yes Attach a full copy of your UNHCR Resettlement Registration Form (RRF)

35 Has any person included in this application served in a military organisation (army/airforce/navy) or in a paramilitary organisation?
No
Yes Give details

1. Given name 2. Given name

Country served Country served


Name of military/paramilitary organisation Name of military/paramilitary organisation

Rank in this Rank in this


organisation organisation
Day Month Year Day Month Year
Dates of Dates of
membership From membership From
of this of this
organisation To organisation To
Why did this person leave this organisation? Why did this person leave this organisation?

If you need more space, please attach a separate page with the details
Attach certified copies of any discharge papers if available

842 (Design date 02/18) - Page 24 © COMMONWEALTH OF AUSTRALIA, 2018


36 Has any person included in this application ever lived in a refugee camp, collective accommodation centre for refugees, or detention centre?
No
Yes Give details
Given names of people included in this
Who ran the Dates lived there
Name of camp/centre Location application who lived there
camp/centre?
Day Month Year (if all, write ‘ALL’)

1. From

To

2. From

To

3. From

To

4. From

To

5. From

To

6. From

To

If you need more space, please attach a separate page with the details

37 If selected for an interview about your application, will you need an interpreter?
No
Yes Which language(s)?
ARABIC OR FARSI
If you are selected for an interview we will advise you if you are required to provide your own interpreter

© COMMONWEALTH OF AUSTRALIA, 2018 842 (Design date 02/18) - Page 25


Part H – Employment history
38 For EACH person included in this application, list all the jobs that they have had in the last 15 years and show any periods of unemployment
For each person, start with the latest period of employment and work backwards
Dates of employment
Name of employer Location of employer Type of business Occupation and main duties
Day Month Year

A1 Main applicant

From 15/03/2009 MASOUD MOGHIMI AHVAZ, IRAN PC SHOP SELLING PC


To 15/03/2005
From 30/03/2005 MASOUD MOGHIMI AHVAZ, IRAN PHONE SELLING MOBILE PHONE
To 04/03/2004
From

To

From

To

From

To

From

To

Other applicants
A2 Name KHADIJEH SAEDI

From House wife


To

From

To

From

To

From

To

From

To

A3 Name

From

To

From

To

From

To

A4 Name

From

To

From

To

From

To

842 (Design date 02/18) - Page 26 © COMMONWEALTH OF AUSTRALIA, 2018


(Question 38 continued)
Dates of employment
Name of employer Location of employer Type of business Occupation and main duties
Day Month Year

A5 Name

From

To

From

To

From

To

From

To

A6 Name

From

To

From

To

From

To

From

To

A7 Name

From

To

From

To

From

To

From

To

Name

From

To

From

To

From

To

Name

From

To

From

To

From

To

If you need more space, please attach a separate page with the details
© COMMONWEALTH OF AUSTRALIA, 2018 842 (Design date 02/18) - Page 27
Part I – Language and education
39 For EACH person included in this application, give details of their language Select
How well this person
Given names Main language spoken Other languages spoken speaks English
(insert code from below)

A1 Main applicant MASOUD MOGHIMI ARABIC FARSI,ENGLISH,INDONESIA 2


Other applicants
A2 KHADIJEH SAEDI PERSIAN ENGLISH,INDONESIA 2

A3 HANI MOGHIMI FARSI ENGLISH 2

A4 OMAR MOGHIMI ENGLISH ENGLISH 3

A5

A6

A7

If you need more space, please attach a separate page with the details

40 For EACH person included in this application, give details of their education
Highest educational
Primary school Secondary school Post-secondary education qualification obtained
Given names
(eg. school certificate, electrician
Day Month Year Day Month Year Day Month Year certificate, BA, PhD)

A1 Main applicant From 24/09/1988 From 23/09/1993 From 23/09/1997


To 20/06/1993 To 20/06/1997 To 12/09/1999
Other applicants
A2 KHADIGEH SAEDI From 20/09/1988 From 23/09/1993 From 23/09/1997
To 20/06/1988 To 20/06/1997 To 20/09/1998

A3 HANI MOGHIMI From 09/7/2017 From From

To 09/07/2017 To To

A4 From From From

To To To

A5 From From From

To To To

A6 From From From

To To To

A7 From From From

To To To

From From From

To To To

From From From

To To To

If you need more space, please attach a separate page with the details
English language codes
1 = Very well (eg. can speak English with little hesitation and few errors in most situations)
2 = Well (eg. can speak English well enough to deal with basic social and work situations)
3 = Not well (eg. can speak only a little English)
4 = Not at all

842 (Design date 02/18) - Page 28 © COMMONWEALTH OF AUSTRALIA, 2018


Part J – Health • had any outstanding debts to the Australian
Government or any public authority in
41 Have you, or any other person included in this application, undergone a Australia? No Yes
health examination for an Australian visa in the last 12 months? If you answered ‘Yes’ to any of the questions at Question 42, provide all
No details below. If the matters relate to a criminal conviction, please give
the nature of the offence, full details of sentence and dates of any period
Yes Give details (including HAP ID if available)
of imprisonment or other detention.

Part K – Character
42 Has any person included in this application ever:
• been charged with any offence that is
currently awaiting legal action? No Yes
• been convicted of an offence in any country
(including any conviction which is now
removed from official records)? No Yes
• been the subject of an arrest warrant or
Interpol notice? No Yes
• been found guilty of a sexually based offence
involving a child (including where no
conviction was recorded)? No Yes
• been named on a sex offender register? No Yes
If you need more space, please attach a separate page with the details
• been acquitted of any offence on the grounds
of unsoundness of mind or insanity? No Yes
• been found by a court not fit to plead? No Yes
• been directly or indirectly involved in, or
associated with, activities which would
represent a risk to national security in
Australia or any other country? No Yes
• been charged with, or indicted for: genocide,
war crimes, crimes against humanity, torture,
slavery, or any other crime that is otherwise of
a serious international concern? No Yes
• been associated with a person, group or
organisation that has been/is involved in
criminal conduct? No Yes
• been associated with an organisation engaged
in violence or engaged in acts of violence
(including war, insurgency, freedom fighting,
terrorism, protest) either overseas or in
Australia? No Yes
• served in a military force, police force, state
sponsored/private militia or intelligence
agency (including secret police)? No Yes
• undergone any military/paramilitary training,
been trained in weapons/explosives or in the
manufacture of chemical/biological products? No Yes
• been involved in people smuggling or people
trafficking offences? No Yes
• been removed, deported or excluded from any
country (including Australia)? No Yes
• overstayed a visa in any country (including
Australia)? No Yes

© COMMONWEALTH OF AUSTRALIA, 2018 842 (Design date 02/18) - Page 29


Part L – Assistance with this form Part M – Options for receiving
43 Did you receive assistance (other than clerical or translation assistance)
communications
in completing this form?
47 All communications about this application should be sent to:
No Go to Part M (Tick one box only)
Yes Please give details of the person or organisation who
Myself
assisted you
OR
Title: Mr Mrs Miss Ms Other
Proposer All communications will be sent to the proposer
Family name only provided in form 681.
Note: If you are applying in the Community
Given names OR Support Program, you should select this option.

Organisation Myself and


proposer
Address
OR

Authorised You should complete form 956A Appointment


recipient or withdrawal of an authorised recipient
Postcode
OR
Telephone number or daytime contact
Country code Area code Number Migration agent Your migration agent/exempt person should
complete form 956 Advice by a migration
Office hours ( ) ( ) OR agent/exempt person of providing immigration
Exempt person assistance
Mobile/cell

44 Is the person an agent registered with the Office of the Migration Agents
Registration Authority (Office of the MARA)?
No
Yes Go to Part M

45 Is the person/agent in Australia?


No Go to Part M
Yes

46 Did you pay the person/agent and/or give a gift for this assistance?
No
Yes

842 (Design date 02/18) - Page 30 © COMMONWEALTH OF AUSTRALIA, 2018


Part N – Australian values statement
48 AUSTRALIAN VALUES STATEMENT
Signature
This statement must be signed by the main applicant and each person of main
aged 18 years or over who is included in this application.
I confirm that I have read, or had explained to me, information provided
applicant ✍
MASOUD MOGHIMI
by the Australian Government on Australian society and values.
I understand: Signature of
• Australian society values respect for the freedom and dignity of the dependent
individual, freedom of religion, commitment to the rule of law, applicant ✍
Parliamentary democracy, equality of men and women and a spirit of
egalitarianism that embraces mutual respect, tolerance, fair play and Name KHADIJEH SAEDI
compassion for those in need and pursuit of the public good;
• Australian society values equality of opportunity for individuals, Signature of
regardless of their race, religion or ethnic background; dependent
• the English language, as the national language, is an important applicant ✍
unifying element of Australian society.
I undertake to respect these values of Australian society during my stay Name
in Australia and to obey the laws of Australia.
I understand that, if I should seek to become an Australian citizen: Signature of
dependent
• Australian citizenship is a shared identity, a common bond which
unites all Australians while respecting their diversity;
applicant ✍
• Australian citizenship involves reciprocal rights and responsibilities. Name
The responsibilities of Australian citizenship include obeying
Australian laws, including those relating to voting at elections and
Signature of
serving on a jury.
dependent
If I meet the legal qualifications for becoming an Australian citizen and
my application is approved I understand that I would have to pledge my
applicant ✍
loyalty to Australia and its people.
Name

Signature of
dependent
applicant ✍
Name

Signature of
dependent
applicant ✍
Name

Signature of
dependent
applicant ✍
Name

© COMMONWEALTH OF AUSTRALIA, 2018 842 (Design date 02/18) - Page 31


Part O – Biometrics declaration and consent
49 BIOMETRICS DECLARATION AND CONSENT
Signature
This declaration and consent must be signed by the main applicant and or mark of
each accompanying person aged 16 years or over.
If I am requested or required to provide my fingerprints and facial image:
applicant ✍
Day Month Year
I consent to:
Date 24/05/201
• the collection of my fingerprints and facial image; and
• if applicable, the collection of the fingerprints and facial image of Signature
each accompanying person under 16 years of age. or mark of
partner
I declare that:
(if applicable) ✍
• I understand that my fingerprints and facial image and my
Day Month Year
biographical information (and those of each accompanying person
under 16 years of age) held by the Department may be given to Date 23 /05/2019
Australian law enforcement agencies to help identify me and each
accompanying person, to help determine my eligibility and the
Signatures of persons aged 16 years or over who are included in this
eligibility of each accompanying person for grant of the visa applied
application (if applicable)
for, and for law enforcement purposes; and
• I understand that my identifying information, including my facial
image, and other personal information (and those of each Signature
or mark
accompanying person under 16 years of age) may be disclosed to
the Department of Social Services (DSS) and its contracted service

Day Month Year
providers for the purposes of establishing my (and each
accompanying person’s) eligibility and need for settlement services, Date
and providing those services.
I consent to:
Signature
• the Department’s disclosure of my identifying information, including or mark
my facial image, and other personal information (and those of each ✍
accompanying person under 16 years of age) to DSS and its Day Month Year
contracted service providers for the purposes outlined above;
Date
• Australian law enforcement agencies disclosing my biometric,
biographical and criminal record information (and that of each
accompanying person under 16 years of age) to the Department for Signature
any of the purposes outlined above; and or mark
• the Department using the information obtained for the purposes of ✍
the Migration Act 1958 or the Australian Citizenship Act 2007. Day Month Year

Date

Signature
or mark

Day Month Year

Date

Signature
or mark

Day Month Year

Date

Signature
or mark

Day Month Year

Date

842 (Design date 02/18) - Page 32 © COMMONWEALTH OF AUSTRALIA, 2018


Part P – Declaration WARNING: Giving false or misleading information is a serious offence.

Signature
Warning: The Migration Act contains a power to cancel a visa if a or mark of
person has made an incorrect statement in relation to their
application. If it is determined that you have concealed information,
applicant ✍
Day Month Year
such as an offence, your application to enter Australia may be
refused. If you have already been granted a visa and it is Date 24 05 2019
subsequently discovered that you have concealed information, such
as an offence, your visa will be liable to cancellation and you may be Signature
refused entry to Australia. In the event that you have already entered or mark of
partner
Australia your visa will be liable to cancellation and, if cancelled, you
may be detained and removed from Australia. (if applicable) ✍
Day Month Year

Date 23 05 2019
50 This declaration must be signed by you (the main applicant) and ALL
persons aged 18 or over included in this application.
Signatures of persons aged 18 years or over who are included in this
I declare that:
application (if applicable)
• the information I have supplied on and with this form is complete,
correct and up-to-date in every detail.
Signature
• I did not marry or enter a de facto relationship to become eligible for
or mark
entry to Australia. ✍
• I understand that if I have given false or misleading information, my Day Month Year
application may be refused, or, if a visa has been granted, the visa
may be cancelled and I could be removed from Australia. Date
• I understand that if I am granted a visa, any person not included in
this application will not have automatic right of entry to Australia by Signature
way of this application. or mark
• I undertake to inform the Australian Government of any material ✍
changes to my circumstances while my application is being Day Month Year
considered, or before I am immigration cleared. Date
(Note: Your visa may be cancelled and you could be removed if you
do not advise of changes in circumstances).
• I authorise the Australian Government to make any enquiries Signature
necessary to determine my eligibility for entry to Australia, and to use or mark
any information supplied in this application for that purpose. ✍
Day Month Year
• I understand that unless my qualifications have already been
recognised by an Australian assessing authority before my departure, Date
they may not be recognised after my arrival.
• I understand that it is my personal responsibility to assess my own
Signature
employment prospects in Australia and acknowledge that labour
or mark
market conditions there can vary significantly from time to time and
between regions.

Day Month Year
• I understand that grant of a visa provides no guarantee of
employment once in Australia. Date
• I have read the information contained in form 1442i Privacy notice.
• I understand the Department may collect, use and disclose my Signature
personal information (including biometric information and other or mark
sensitive information) as outlined in form 1442i Privacy notice. ✍
• I understand that information collected in the visa process may be Day Month Year
disclosed to other agencies and contracted service providers for the Date
purposes of evaluating my settlement needs and providing
settlement support.
For applicants applying in the Community Support Program: Signature
or mark
• I understand that my Approved Proposing Organisation will be
lodging this application on my behalf.

Day Month Year
• I understand that the information that I provide in this form may be
shared with my Approved Proposing Organisation and that my Date
Approved Proposing Organisation may also share this information
with any Supporting Community Organisations it works with in order We strongly advise that you keep a copy of your application
to provide services to help me settle in Australia. and all attachments for your records.

Important: If your circumstances change after you lodge this application (eg. you change your address, marry or become engaged to be married, or have
a baby), you must notify the office where you lodge this application. If your application is supported by a proposal form 681 Refugee and special
humanitarian proposal or form 1417 Community Support Program Proposal by Approved Proposing Organisations and your proposer’s circumstances
change after you have lodged this application, you should also notify the office where you lodge this application.
© COMMONWEALTH OF AUSTRALIA, 2018 842 (Design date 02/18) - Page 33
Part Q – Document checklist Question Document Attached?
Q22 Certified* copies of travel documents and/or
This checklist is provided to help you submit a complete, decision-ready identity cards held by any person included in
application. If you do not have any of the requested documents (originals this application (if available)
or certified* copies) listed below, please provide an explanation as to
OR
why you no longer have these documents.
A statement explaining why you have no
travel/identity documents
UNDER NO CIRCUMSTANCES SHOULD YOU SUBMIT FALSE
DOCUMENTS Q24 Certified* copies of any visas/residence
permits held by any person included in this
51 Have you attached the following documents? application (if available)

Question Document Attached? Q28 A detailed written statement (in English),


clearly explaining the reasons why you fear
Two (2) recent passport size photographs of living in or returning to your home country
each person included in your application,
with the full name of the person written Q34 If you have been referred for resettlement by
on the back of each photograph the UNHCR, a full copy of your UNHCR
Resettlement Registration Form (RRF)
Q2 & 3 Evidence of the identity of each person
Q35 Certified* copies of any discharge papers
included in this application (eg. certified*
(if available)
copies of birth certificates, marriage
certificates, passport, national identity card
etc.), if available • If you have attached additional pages with answers, each page
Q4 Evidence of registration with any international must be marked with the question number it refers to, and
organisation dealing with refugees signed and dated by each person aged 18 years or over who is
(eg. UNHCR), if applicable included in this application.
• Please ensure you, your partner and persons aged 18 years or over
Q9 Certified* copies of previous marriage/divorce who are included in this application have signed the Declaration at
papers, or death certificates (if applicable) Part P.
Q10 Certified* copies of child custody papers • If you do not provide all the necessary documents, or you have not
(if applicable) provided an adequate explanation why you cannot provide these
documents, a decision may be made on the information you have
Q11 Certified* copies of adoption papers or a provided. It is in your interest to support your application with as
written statement which explains the much information as possible at the time of lodging this application.
circumstances of adoption (if applicable)
• You must lodge your Class XB visa application at the relevant office
Q18 If your entry to Australia is being proposed by of the Department responsible for visa applications from your country
a person or organisation in Australia, attach a of residence. To find out which office of the Department you need to
fully completed form 681 completed by your lodge your application with, refer to the Department’s website at
proposer www.homeaffairs.gov.au
OR Note: Certain applicants must lodge their application in Australia
(see ‘Where can you lodge this application?’ on page 3).
If your entry to Australia is being proposed by
an Approved Proposing Organisation under
the Community Support Program, attach a
fully completed form 1417 completed by your
Approved Proposing Organisation
Q19 If you are applying under the ‘split family’
provisions for immediate family members,
please attach:
a certified* copy of your proposer’s visa
evidence of the relationship with your
proposer (eg. a certified* copy of marriage or
birth certificate)
A form 681 completed by your immediate
family member in Australia who is proposing
you
Note: If applying under ‘split family’ provisions,
form 681 must be lodged with the form 842 at
the time you submit this application

* In Australia, copies of documents must be certified as true copies of the original


by a Justice of the Peace, Commissioner for Declarations, or a person before
whom a Statutory Declaration may be made under the Statutory Declarations
Act 1959.
* Outside Australia, copies of documents must be certified by a person who is the
equivalent of a Justice of the Peace or Commissioner for Declarations in the
country where the documents are being certified.
842 (Design date 02/18) - Page 34 © COMMONWEALTH OF AUSTRALIA, 2018

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