Claim for an annual lump sum payment of Family Tax Benefit

Transcription

1 Claim for an annual lump sum payment of Family Tax Benefit A payment to help families with the cost of raising children for the financial year Online Services When to use this form When to Claim Filling in this form Returning your form Use our online services You do not need to complete this form if you use our online services. Claiming online is faster. You can access your Centrelink, 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. create a mygov account, go to make a claim online log into and select Centrelink from the services tab, then select Make a claim. If you do not use our online services, processing this form will take longer. Use this form if you wish to claim Family Tax Benefit for the financial year. te: If you are not able to access our online services, or need assistance to register for an online account, call us on You can claim a lump sum payment of Family Tax Benefit for the financial year (1 July June 2015). You have until 30 June 2016 to lodge your claim for the financial year. You need to call us on if there are special circumstances that prevent you from lodging your claim by this date. 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. Check that all required questions are answered and that the form is signed and dated. You can return this form and any supporting documents: online submit your documents online. For more information about how to access an Online Account or how to lodge documents online, go to www. humanservices.gov.au/submitdocumentsonline by post return your documents by sending them to: Department of Human Services, Families, Reply paid 7802, CANBERRA BC ACT 2610 in person if you are unable to submit this form and any supporting documents online or by post, you can provide them in person to one of our service centres. OFFICE USE ONLY / CUSTOMER RECEIPT Date stamp Once date stamped by us, this receipt is proof that your claim for Family Tax Benefit has been lodged. Customer details Customer name Centrelink Reference Number

2 For more information Online Services You should have received the booklet Information Booklet about your claim for Family Assistance (Ci011) with this form. In this form, this booklet will be referred to as the Information Booklet. If you do not have this booklet, go online or call us on or visit one of our service centres. Go online or call us on or visit one of our service centres. If you need a translation of any documents for our business, we can arrange this for you free of charge. speak to us in languages other than English, call te: Call charges apply calls from mobile phones may be charged at a higher rate. If you have a hearing or speech impairment, you can contact the TTY service on Freecall A TTY phone is required to use this service. If you complete your claim online, and you are eligible, your claim can be assessed faster than if you complete this claim form. You do not need to complete this form if you use our online services. 1 Are you claiming online? Do not complete this form. Go online and select Centrelink from the services tab. Personal details You Your partner (if you have one) 2 Do you need an interpreter when dealing with us? 2 Does your partner need an interpreter when dealing with us? This includes an interpreter for people who have a hearing or speech impairment. This includes an interpreter for people who have a hearing or speech impairment. Go to 4 Go to 4 3 What is your preferred spoken language? 3 What is your partner s preferred spoken language? 4 What is your preferred written language? 4 What is your partner s preferred written language? 5 Your Centrelink Reference Number (if known) 5 Your partner s Centrelink Reference Number (if known) CLK0FA of 54

3 You Your partner on 30 June Do you want to authorise another person or organisation to make enquiries, get Centrelink payments and/or act on your behalf? You will need to complete and attach an Authorising a person or organisation to enquire or act on your behal form (SS313). If you do not have this form or want more information about nominee arrangements, go to our website www. humanservices.gov.au/nominees 7 Did you have a partner on 30 June 2015? When completing the partner s details in this form we are referring to the partner you had on 30 June Your name 8 Your partner s name Mr Mrs Miss Ms Other Mr Mrs Miss Ms Other Family name Family name First given name First given name Second given name Second given name 9 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)? 9 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)? 1 Other name 1 Other name Type of name (e.g. name at birth) Type of name (e.g. name at birth) 2 Other name 2 Other name Type of name (e.g. maiden name) Type of name (e.g. maiden name) If you have more than 2 other names, attach a separate sheet with details. If your partner has more than 2 other names, attach a separate sheet with details. 3 of 54

4 You Your partner on 30 June Your sex Male Female 10 Your partner s sex Male Female 11 Your date of birth 11 Your partner s date of birth 12 Your permanent address 12 Your partner s permanent address (if different to your address) Postcode Postcode 13 Your postal address (if different to above) 13 Your partner s postal address (if different to above) Postcode Postcode 14 Please read this before answering the following questions 14 Please read this before answering the following questions If you provide an address or mobile phone number, you may receive electronic messages (SMS or ) from us. read the Terms and Conditions, go to our website www. humanservices.gov.au/em or visit one of our service centres. If your partner provides an address or mobile phone number, they may receive electronic messages (SMS or ) from us. read the Terms and Conditions, go to our website www. humanservices.gov.au/em or visit one of our service centres. Your contact details Your partner s contact details (if different) Home phone number ( ) Home phone number ( ) Mobile phone number Is this a silent number? Mobile phone number Is this a silent number? Is this a silent number? Is this a silent number? Work phone number ( ) Work phone number ( ) address 4 of 54

5 15 Please read this before answering the following questions 17 Please read this before answering the following question You are not breaking the law if you do not give us your (and your partner s) tax file number(s), but if you do not provide them to us you will not be paid. In giving us your (and your partner s) tax file number in relation to this claim you authorise us to use your (and your partner s) tax file number for other family assistance payments and services in future where necessary. 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 What was your relationship status on 30 June 2015? 16 Have you (and your partner) given us your tax file number(s) before? t sure Go to 17 Do you (and your partner) have a tax file number? Married Registered relationship (opposite-sex or same-sex relationship registered under state or territory laws) Date of marriage Date registered Go to 18 Go to 18 You Please call us on Your tax file number Partnered (living together in an oppositesex or same-sex relationship, including de facto) Date you started living with a partner Go to 18 Your partner Please call us on Your partner s tax file number Separated (previously lived with an oppositesex or same-sex partner, including in a marriage, registered or de facto relationship) Date of last separation Go to 20 Divorced Date of divorce Go to 20 Widowed (previously partnered with an opposite-sex or same-sex partner, including in a marriage, registered or de facto relationship) Never married or lived with a partner Date of partner s death Go to 20 Go to 20 If none of the above describes your relationship status, please call us on If you had a partner on 30 June 2015, were you in a relationship with them for only part of the 19 Do you give permission for your partner to speak with us on your behalf? You can change this authority at any time. 5 of 54

6 20 Please read this before answering the following questions 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 rres 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. 23 Have you EVER lived or travelled outside Australia, including short trips and holidays? This question assists us to verify your Australian residence. Year you last entered Australia Are you (and/or your partner) of Aboriginal or rres Strait Islander Australian origin? If you are of both Aboriginal and rres Strait Islander Australian origin, please tick both boxes. Passport number You Your partner Country of issue 21 Aboriginal Australian rres Strait Islander Australian Aboriginal Australian rres Strait Islander Australian Are you (and/or your partner) of Australian South Sea Islander origin? 24 Are you an Australian citizen who was born in Australia? You will need to provide proof of your Australian residence status (e.g. citizenship papers, passport or other documentation). You Your partner Go to What is your country of birth? Residence details 22 Please read this before answering the following question Permanently means you normally live in Australia on a longterm basis. Holidays or short trips outside Australia would not affect this. Are you living in Australia permanently? When did you most recently start living in Australia? What is your country of citizenship? Australia Date granted Go to 31 Other Country of citizenship 28 What type of visa did you arrive on? New Zealand passport (Special Category Visa) Permanent Temporary Unknown (e.g. arrived on parent s passport) Go to 30 Go to Your visa details on arrival Visa sub class Date visa granted 6 of 54

7 Has your visa changed since you arrived in Australia? Current visa details Visa sub class In the last 3 years, up until 30 June 2015, have you lived outside Australia for any period? If you require more space, attach a separate sheet with details. Account details 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. Departure date Date visa granted Return date Where do you want your lump sum payment made? Blended family details Please read this before answering the following question 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. Are you in a blended family? Go to 36 Please read this before answering the following question 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. Do you and your partner want to be paid your Family Tax Benefit separately? Go to 36 The bank, building society or credit union account must be in your name. A joint account is acceptable. It cannot be in a child s 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. te: Payments cannot be made into an account used exclusively for funding from the National Disability Insurance Scheme. Name of bank, building society or credit union Branch where the account is held Branch number (BSB) Account number (this may not be your card number) Account held in the name(s) of 35 Please read this before answering the following question 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. What percentage of your family s entitlement to Family Tax Benefit do you want to claim? % 7 of 54

8 Rent assistance details 36 Rent Assistance is an additional payment for families who rent their accommodation in the private rental market. This includes paying private rent, board and/or lodging for accommodation. If you are entitled to Rent Assistance it is generally paid fortnightly with your Family Tax Benefit payments. For more information, see Rent Assistance in the Information Booklet. Do you have an eligible child, for Family Tax Benefit purposes, in your care NOW? For more information, see Eligible child in the Information Booklet. 42 Did you (and/or your partner) own a home but live elsewhere? 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 Are you currently receiving fortnightly payments of Family Tax Benefit? Go to 39 Go to 39 Do you want to claim fortnightly payments of Family Tax Benefit? 43 Which of the following best describes where you lived? In a home which was owned by a private company or a private trust that you had an interest in Go to 67 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 Go to 44 Rent Assistance is not payable Do not answer questions 39 to 66. Go to 67 In accommodation which you (and/or your partner) had the right to use for life Go to 48 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). 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) Go to 45 Go to Have you given details about your accommodation to us before? Go to 41 Were your accommodation details different in the financial year to those you have provided, or will provide on your fortnightly payments claim form? In a boarding house/hostel/private hotel Other (e.g. this could be a place where you (and/or your partner) did not have a fixed address) Go to 55 In accommodation where you did not pay rent Go to 67 Give details below Do not answer questions 41 to 64. Go to 65 t sure Go to Please read this before answering the following question If you changed accommodation several times during the financial year, attach a separate sheet with your accommodation details (in questions 42 to 63) for each period. 44 Did you pay site, ground or mooring fees for the home you owned (this could be for a caravan, transportable home or boat)? Do not answer questions 45 to 66. Go to 67 Go to 53 8 of 54

9 45 Were you (and/or your partner) the primary tenant? 51 Details of the payment/transfer That is, your (and/or your partner s) name was on the rental contract (lease) with the public housing authority. How much did you (and/or your partner) pay? Do not answer questions 46 to 66. Go to 67 AND/OR What assets were transferred? 46 Did the primary tenant pay rent at the market rate? t sure Go to 54 Market value of assets transferred? 47 Did you (and/or your partner) live with the primary tenant AND your (and/or your partner s) income was taken into account by the public housing authority when calculating the rent? 52 Details of the person or organisation that the payment/transfer was made to Full name (of the person or organisation) Do not answer questions 48 to 66. Go to 67 Go to 54 Address 48 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? Postcode Go to What type of accommodation did you (and your partner) live in? 49 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: Private house or townhouse/unit/flat Community housing Defence housing Inherited the life interest Go to 67 Caravan/cabin/mobile home 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 53 Boat Boarding house/hostel/private hotel Other Go to 55 Had an informal arrangement, no rent paid Go to 67 Other Give details below Go to What date did you (and/or your partner) make this payment/transfer? 9 of 54

10 54 Please read this before answering the following question 54 Continued 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). Did you (and your partner) share your accommodation with other people? Go to 55 1 Person s name 4 Age Person s name Relationship to you Their share of the rent/lodgings Period this person shared per Do they own the home? Age Relationship to you If you shared with more than 4 people, attach a separate sheet with details. Their share of the rent/lodgings per Period this person shared Do they own the home? 55 Did you (and/or your partner) pay board and/or lodgings? 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). 2 Age Person s name Relationship to you 56 Go to 57 Can you separate the amounts you (and/or your partner) paid for board and/or lodgings? tal board and lodgings charged per day, week, fortnight, 4 weeks or calendar month Their share of the rent/lodgings Do they own the home? per Period this person shared 3 Person s name per Amount paid for board (meals) per day, week, fortnight, 4 weeks or calendar month per Amount paid for lodgings (accommodation only) per day, week, fortnight, 4 weeks or calendar month per Age Relationship to you Go to 58 Their share of the rent/lodgings Period this person shared per Do they own the home? 57 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. per 10 of 54

11 58 When did you (and/or your partner) start paying this amount? 65 If you had a partner in the financial year, did you live with them for the entire year? This question is to determine if you are eligible for a higher amount of Rent Assistance. 59 Did you (and/or your partner) live in a boarding house, hostel, private hotel, hospital or disability housing? Go to 61 Did not have a partner Go to 67 Go to What was the total amount of rent charged for the property per day, week, fortnight, 4 weeks or calendar month? per Details of your landlord, authorised agent or person you (and/or your partner) paid rent to Full name 66 Was this separation: for medical reasons? temporary? because your partner was in prison? What were the periods of the separation? Address Contact phone number ( ) Postcode 62 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? Attach a full copy of your current lease or tenancy agreement which must include the terms and conditions. 63 During what period did you live in this accommodation? 64 Did your accommodation details change in the financial year? You will need to answer questions 42 to 63 for each type of accommodation you lived in during the financial year, attach a separate sheet with details. 11 of 54

12 Child details 67 Please read this before answering the following questions Give the following details for each child who was in your care during the financial year (1 July June 2015). 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 financial year, photocopy and attach pages 12 to 19 for each additional child before completing the details for child 1. Child 1 68 Child s family name Child s first given name 74 Was this child part of a multiple birth, multiple entrustment to care or multiple adoption? Child s second given name 69 Has this child been known by any other names? 70 Child s sex Male Female List the other names 71 Child s date of birth 75 The term parent refers to a natural or adoptive parent or a person who is legally responsible for a child born through an assisted conception procedure or where a surrogacy court order is in place. Your partner s (if you have one) relationship to this child Birth mother Partner of birth mother Adoptive parent Biological father Partner of biological father Grandparent Foster parent (formal) Foster parent (informal) Other 72 What is this child s country of birth? 76 Your relationship to this child Birth mother Partner of birth mother Go to Has this child EVER lived or travelled outside Australia, including short trips and holidays? This question assists us to verify this child s Australian residence. Passport number Adoptive parent Biological father Partner of biological father Grandparent Foster parent (formal) Foster parent (informal) Other Go to 82 Go to 78 Go to 78 Go to 80 Go to 80 Go to 80 Country of issue Go to Have you given birth to any other children (excluding stillborn children) before this child? Go to 84 Go to of 54

13 Child 1 78 Did this child enter your (and/or your partner s) care as part of a surrogacy arrangement? Go to Has the birth mother of this child given birth to any other children (excluding stillborn children)? Go to 84 Go to Have you (and/or your partner) previously had a child entrusted to your care? 81 Did you have this child in your care for at least 13 consecutive weeks? Go to 84 Go to Have you (and/or your partner) adopted a child before this child? 83 Did you (and/or your partner) adopt this child as part of a known adoption? 84 Have you (or your partner) previously claimed Parental Leave Pay for this child? Go to Do you intend to claim Parental Leave Pay for this child? 86 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 Who are the parents of this child? Parent 1 Is this person deceased? Date of death Parent 2 Is this person deceased? Date of death 87 Was this child under 4 years of age during the financial year? Go to Was this child under 16 years of age on 30 June 2015? Go to Was this child studying during the Go to 92 Highest level of study during Primary education Full-time secondary study Special education Date this child started studying at this level 90 Was this child studying by registered home schooling or study outside Australia? Registered home schooling Study outside Australia 13 of 54

14 Child 1 91 Did this child cease or complete primary, full-time secondary or special education during the Primary education Full-time secondary study Special education Date this child started studying at this level 92 Was this child granted an exemption from studying by your state or territory education authority? Go to 97 Primary education Full-time secondary study Special education Reason for exemption Date this child finished studying at this level 94 Did this child complete a Year 12 or equivalent qualification before 1 July 2014? Go to 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 Did this child repeat Year 12 during the financial year? Go to Start date Was this child under 20 years of age on 30 June 2015? Go to 97 Date this circumstance will cease or ceased Do not answer anymore questions for this child. Go to Was this child a full-time student for the entire financial year? Period of full-time study Go to 102 Go to Did this child turn 1, 2 or 5 years of age during the Go to of 54

15 Child 1 98 Please read this before answering the following question be eligible for Family Tax Benefit Part A supplement, you will need to meet the immunisation requirements for the financial years your 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. do this you need to provide details of the current Medicare card the child is listed on so that we can confirm this child s immunisation is up-to-date, or that they have an approved exemption. Is this child listed on a current Medicare card? Number on the current Medicare card Child s Medicare reference number (if applicable) Reference First given name and second initial Number 100 Please read this before answering the following question For a secondary or equivalent course, the course completion day is usually the last day of the final term of your child s 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. Was this child in education or training (including school based apprenticeships or traineeships) during the financial year? 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) Course title (e.g. NSW Higher School Certificate or Certificate Level II in Hospitality) 99 Was this child under 4 years of age on 30 June 2015? Go to 105 Date this child first enrolled or started study, whichever is earlier Date this child completed or will complete this course Was this child enrolled: Full-time Less than full-time Go to Was there a reason this child was not in full-time education or training during the For example, exemption from study. Start date Date this circumstance will cease or ceased 15 of 54

16 Child Did this child receive any of the following payments or education allowances during the Carer Payment Community Development Employment Projects (CDEP) Participant Supplement Disability Support Pension Disability Support Pension (Blind) Parenting Payment Sickness Allowance Special Benefit Youth Allowance Veterans' Children Education Scheme (VCES)/Military Rehabilitation and Compensation Act Education and Training Scheme (MRCAETS) paid by the Department of Veterans' Affairs. Go to Did this child receive payment(s) for the entire financial year? This child is not an eligible Family Tax Benefit child do not answer any more questions for THIS child. Go to Did this child receive ABSTUDY (do not include Schooling A) during the Certain allowances can be received in addition to Family Tax Benefit. 105Do you have a child support care percentage determination for this child? 106Did this child come into your care from someone else during the Go to 110 Who cared for this child before you? Name 107When did this child enter your care? 108 What periods in did this child live with you? 109 Do you have legal or other documents to support the change of care? Attach a copy of this document. 110 Did this child spend time in care with someone else other than you (and/or your partner at 30 June 2015) such as their other parent if you were separated, grandparent or other carer during the financial year (e.g. weekends, school holidays)? be paid any Family Tax Benefit, you must have care of this child for at least 35 per cent of the time during the financial year. 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. Name Address Go to 119 Who did this child spend time with? Postcode Address Contact phone number (if known) ( ) Postcode 16 of Did you have a parenting plan, court order or written agreement for the period during the Go to 114 Attach a copy of the parenting plan, court order or written agreement.

17 Child Was the parenting plan, court order or written agreement complied with during the Go to Was the shared care arrangement for this child for the full Go to Provide the periods of shared care for this child during the financial year 116 Did this child leave your care for MORE than a short period during the A short period is generally a period less than 4 consecutive weeks. 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. Go to 119 Provide the periods during which this child was not in your care If there are more dates, attach a separate sheet with details. If there are more dates, attach a separate sheet with details. 115 Please read this before answering the following question 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 % OR How many nights was this child in your care during the 117 Was this with your consent? Go to Did you take reasonable action to regain care of this child? 119 Did this child die during the If a child died, you may be eligible to receive a bereavement payment. Date of death We will contact you to provide more information. 17 of 54

18 Child 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 2015) were entitled to receive and actually received during the financial year. Is this child from a previous relationship? Go to 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 Go to Did you (and/or your partner) have a current child support assessment for this child during the 123 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 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 125 Action taken by: You Go to 125 Your partner 124 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. 125 whom were you (and/or your partner) entitled to receive child support for this child during the 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. Full name(s) 126 Please read this before answering the following questions Child support can include cash, capitalised maintenance/ lump sum payment(s) and non-cash amounts. n-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. n-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. 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 You will need to tell Child Support services if you received any additional child support (including cash, a lump sum payment or non cash). 127 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 Go to 130 Go to of 54

19 Child Please read this before answering the following question 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. Did this amount include any child support arrears that were owed to you for a private collect period before 1 July 2012? 129 Did you receive any voluntary child support for this child during the Go to 133 How much was received Go to Please read this before answering the following questions 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. Did you (and/or your partner), change from Child Support services collect to private collect, at any time during the Go to 130 What was the total additional child support received for this child during the Go to 132 Go to Did you (and/or your partner) receive any child support in relation to this child having a disability or learning difficulty during the How much was received: Through Child Support services Privately 133 Please read this before answering the following questions Apart from Family Tax Benefit, there are other payments or assistance that families may be entitled to receive. Does this child have a disability? Go online for more information about Carer Allowance and/or Carer Payment. 134 Is this child an orphan? For more information and our definition of an orphan, see Double Orphan Pension in the Information Booklet. 135 Did you have another child, during the financial year, for whom you wish to claim a lump sum payment of Family Tax Benefit? Go to 136 on page 44 on the next page 131 Did you (and/or your partner) discharge any child support arrears during the What was the amount of arrears you discharged? On what date did you discharge the arrears? 19 of 54

20 Child 2 68 Child s family name Child s first given name 74 Was this child part of a multiple birth, multiple entrustment to care or multiple adoption? Child s second given name 69 Has this child been known by any other names? 70 Child s sex Male Female List the other names 71 Child s date of birth 75 The term parent refers to a natural or adoptive parent or a person who is legally responsible for a child born through an assisted conception procedure or where a surrogacy court order is in place. Your partner s (if you have one) relationship to this child Birth mother Partner of birth mother Adoptive parent Biological father Partner of biological father Grandparent Foster parent (formal) Foster parent (informal) Other 72 What is this child s country of birth? 76 Your relationship to this child Birth mother Partner of birth mother Go to Has this child EVER lived or travelled outside Australia, including short trips and holidays? This question assists us to verify this child s Australian residence. Adoptive parent Biological father Partner of biological father Grandparent Go to 82 Go to 78 Go to 78 Go to 80 Passport number Foster parent (formal) Foster parent (informal) Other Go to 80 Go to 80 Country of issue Go to Have you given birth to any other children (excluding stillborn children) before this child? Go to 84 Go to of 54

21 Child 2 78 Did this child enter your (and/or your partner s) care as part of a surrogacy arrangement? Go to Has the birth mother of this child given birth to any other children (excluding stillborn children)? Go to 84 Go to Have you (and/or your partner) previously had a child entrusted to your care? 81 Did you have this child in your care for at least 13 consecutive weeks? Go to 84 Go to Have you (and/or your partner) adopted a child before this child? 83 Did you (and/or your partner) adopt this child as part of a known adoption? 84 Have you (or your partner) previously claimed Parental Leave Pay for this child? Go to Do you intend to claim Parental Leave Pay for this child? 86 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 Who are the parents of this child? Parent 1 Is this person deceased? Date of death Parent 2 Is this person deceased? Date of death 87 Was this child under 4 years of age during the financial year? Go to Was this child under 16 years of age on 30 June 2015? Go to Was this child studying during the Go to 92 Highest level of study during Primary education Full-time secondary study Special education Date this child started studying at this level 90 Was this child studying by registered home schooling or study outside Australia? Registered home schooling Study outside Australia 21 of 54

22 Child 2 91 Did this child cease or complete primary, full-time secondary or special education during the Primary education Full-time secondary study Special education Date this child started studying at this level 92 Was this child granted an exemption from studying by your state or territory education authority? Go to 97 Primary education Full-time secondary study Special education Reason for exemption Date this child finished studying at this level 94 Did this child complete a Year 12 or equivalent qualification before 1 July 2014? Go to 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 Did this child repeat Year 12 during the financial year? Go to Start date Was this child under 20 years of age on 30 June 2015? Go to 97 Date this circumstance will cease or ceased Do not answer anymore questions for this child. Go to Was this child a full-time student for the entire financial year? Period of full-time study Go to 102 Go to Did this child turn 1, 2 or 5 years of age during the Go to of 54

23 Child 2 98 Please read this before answering the following question be eligible for Family Tax Benefit Part A supplement, you will need to meet the immunisation requirements for the financial years your 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. do this you need to provide details of the current Medicare card the child is listed on so that we can confirm this child s immunisation is up-to-date, or that they have an approved exemption. Is this child listed on a current Medicare card? Number on the current Medicare card Child s Medicare reference number (if applicable) Reference First given name and second initial Number 100 Please read this before answering the following question For a secondary or equivalent course, the course completion day is usually the last day of the final term of your child s 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. Was this child in education or training (including school based apprenticeships or traineeships) during the financial year? 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) Course title (e.g. NSW Higher School Certificate or Certificate Level II in Hospitality) 99 Was this child under 4 years of age on 30 June 2015? Go to 105 Date this child first enrolled or started study, whichever is earlier Date this child completed or will complete this course Was this child enrolled: Full-time Less than full-time Go to Was there a reason this child was not in full-time education or training during the For example, exemption from study. Start date Date this circumstance will cease or ceased 23 of 54

24 Child Did this child receive any of the following payments or education allowances during the Carer Payment Community Development Employment Projects (CDEP) Participant Supplement Disability Support Pension Disability Support Pension (Blind) Parenting Payment Sickness Allowance Special Benefit Youth Allowance Veterans' Children Education Scheme (VCES)/Military Rehabilitation and Compensation Act Education and Training Scheme (MRCAETS) paid by the Department of Veterans' Affairs. 106Did this child come into your care from someone else during the Go to 110 Name Go to Did this child receive payment(s) for the entire financial year? This child is not an eligible Family Tax Benefit child do not answer any more questions for THIS child. Go to Did this child receive ABSTUDY (do not include Schooling A) during the Certain allowances can be received in addition to Family Tax Benefit. 105Do you have a child support care percentage determination for this child? Who cared for this child before you? 107When did this child enter your care? 108 What periods in did this child live with you? 109 Do you have legal or other documents to support the change of care? Attach a copy of this document. 110 Did this child spend time in care with someone else other than you (and/or your partner at 30 June 2015) such as their other parent if you were separated, grandparent or other carer during the financial year (e.g. weekends, school holidays)? be paid any Family Tax Benefit, you must have care of this child for at least 35 per cent of the time during the financial year. 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. Name Address Go to 119 Who did this child spend time with? Postcode Address Contact phone number (if known) ( ) Postcode 24 of Did you have a parenting plan, court order or written agreement for the period during the Go to 114 Attach a copy of the parenting plan, court order or written agreement.

25 Child Was the parenting plan, court order or written agreement complied with during the Go to Was the shared care arrangement for this child for the full Go to Provide the periods of shared care for this child during the financial year 116 Did this child leave your care for MORE than a short period during the A short period is generally a period less than 4 consecutive weeks. 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. Go to 119 Provide the periods during which this child was not in your care If there are more dates, attach a separate sheet with details. If there are more dates, attach a separate sheet with details. 115 Please read this before answering the following question 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 % OR How many nights was this child in your care during the 117 Was this with your consent? Go to Did you take reasonable action to regain care of this child? 119 Did this child die during the If a child died, you may be eligible to receive a bereavement payment. Date of death We will contact you to provide more information. 25 of 54

26 Child 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 2015) were entitled to receive and actually received during the financial year. Is this child from a previous relationship? Go to 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 Go to Did you (and/or your partner) have a current child support assessment for this child during the 123 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 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 125 Action taken by: You Go to 125 Your partner 124 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. 125 whom were you (and/or your partner) entitled to receive child support for this child during the 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. Full name(s) 126 Please read this before answering the following questions Child support can include cash, capitalised maintenance/ lump sum payment(s) and non-cash amounts. n-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. n-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. 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 You will need to tell Child Support services if you received any additional child support (including cash, a lump sum payment or non cash). 127 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 Go to 130 Go to of 54