Disaster Recovery Allowance Tropical Cyclone Marcia (Qld) February 2015

Disaster Recovery Allowance Tropical Cyclone Marcia (Qld) February 2015 1 Do you need an interpreter when dealing with us? 7 Do any of the following apply to you? This includes an interpreter for people who have a hearing or speech impairment. To speak to us in languages other than English, call 131 202. Tick ALL that apply Live in an affected area Suburb Go to 3 Work in the affected area Suburb 2 What is your preferred spoken language? Derive income from the affected area Suburb 3 What is your preferred written language? ne of the above You may not be eligible for this assistance. Please call us on 180 22 66. 4 Do you have a Centrelink Reference Number? 8 Have you lost or suffered a reduction in your income as a direct result of the disaster? Your Centrelink Reference Number (if known) You may not be eligible for this assistance. Please call us on 180 22 66. 5 Are you receiving an income support payment or pension (e.g. Age Pension, Newstart Allowance, Service Pension from the Department of Veterans Affairs or Farm Household Allowance)? 9 Are you 22 years of age or older? Go to 14 You may not be eligible for this assistance. Please call us on 180 22 66. 10 Please read this before answering the following questions. 6 Do any of the following apply to you? Tick the first option that applies to you Questions 10 13 are to be completed ONLY if you are under 22 years of age. Are you a parent or have a dependent child in your care? An Australian citizen A permanent visa holder A New Zealand passport holder Holder of an eligible temporary visa Refer to the factsheet for a list of eligible temporary visa classes. Go to 14 ne of the above You may not be eligible for this assistance. Please call us on 180 22 66. CLK0EM091 150227 1 of 11

11 What is your estimated income for the current financial year? 18 What was your place of residence at the time of the disaster? 12 Are you wholly or substantially dependent on another person? Refer to the factsheet for an explanation of wholly or substantially dependent. 19 Postcode What is the address of your current residence? (if different to above) 13 Are you currently living with your parent(s) or guardian(s)? Postcode Is this a temporary residence? 14 Your name Mr Mrs Miss Ms Other 20 Postal address (if different to above) Family name First given name Postcode 15 Second given name 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)? 21 IMPORTANT This payment can be paid for a maximum period of 13 weeks dependent on your circumstances. Before the end of the 13 weeks we will contact you to advise of the required steps that must be taken if you require further assistance. Please ensure your contact details are always up to date. How can we contact you? Other name Phone number ( ) To help us serve you better, please provide your mobile number Mobile phone number Type of name (e.g. name at birth) te: This mobile number will automatically be subscribed to our electronic messaging service. We may use this mobile number to contact you. For Terms and Conditions, go to our website www.humanservices.gov.au/em 16 If you have more than 1 other name, attach a separate sheet with details. Your sex Male Female 22 23 Were you in Australia when the disaster occurred? Go to 24 When did you return to Australia after the disaster? 17 Your date of birth 2 of 11

24 Please read this before answering the following questions. 31 Are you subject to an Assurance of Support agreement? Permanently means you normally live in Australia on a long-term basis. Holidays or short trips outside Australia would not affect this. What is the name of your Assurer? Are you living in Australia permanently? 25 Have you lived or travelled outside Australia since 1 September 1994, including short trips and holidays? The answer to this question may enable Human Services to access electronic records held by Australia s immigration department and help verify your Australian residence. 32 Except for short trips or holidays, have you EVER lived outside Australia? If you were born outside Australia, include the country where you were born. Include the period(s) you have lived in each country. Do NOT include short trips or holidays. 1 Country of residence Passport number From To Country of issue 2 Country of residence 26 Are you an Australian citizen who was born in Australia? From To Go to 32 You will need to provide proof of your Australian residence status (e.g. citizenship papers, passport or other documentation). 33 If you require more space, attach a separate sheet with details. Do you have a partner? Go to 42 27 What is your country of birth? 34 Does your partner have a Centrelink Reference Number? 28 What is your country of citizenship? Your partner s Centrelink Reference Number (if known) Australia Other Date you became an Australian citizen Country of citizenship Go to 31 35 Your partner s name Mr Mrs Miss Family name Ms Other 29 What is your current type of visa? New Zealand passport Go to 32 (special category visa) Permanent Temporary Unknown (e.g. arrived Go to 31 on parent s passport) First given name Second given name 30 Your visa details on arrival Visa sub class Date visa granted 3 of 11

36 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)? 43 of your youngest dependent child Child s family name Child s given names Other name Other name this child has been known by Type of name (e.g. name at birth) Child s date of birth Child s sex Male Female 37 38 39 40 If your partner has more than 1 other name, attach a separate sheet with details. Your partner s sex Male Female Your partner s date of birth Does your partner live at the same residential address as you? Go to 41 Your partner s residential address Are you the principal carer of this child? Is there a shared care arrangement in relation to this child? What is your percentage of shared care? Do you receive Family Tax Benefit for this child? 44 Provide details of your usual work (e.g. employment, self-employment, sub-contracting, farming). Employer s name, business name or farm name Australian Business Number (ABN) Address 41 42 Do you give permission for your partner to discuss details about your claim? Postcode Do you have dependent children under 16 years of age in your care? Phone number ( ) Postcode What industry are you employed in? For example: a banana industry should write: Agriculture banana industry a clothes shop assistant should write: Retail clothes. te: There are no additional payments for dependent children. If you currently receive Family Tax Benefit you may need to revise your income estimate. Is this work Full-time Part-time Seasonal Casual Go to 44 Other Give details Was your income from this employer impacted as a result of the disaster? If you have more than one employer, attach a separate sheet with details. You must answer questions 44 to 53 for each employer. 4 of 11

45 Are you self-employed? The income you receive from self-employment must be included at question 65 and question 69. 46 What date did you stop working or first incur a reduction in your income as a result of the disaster? 47 Which one of the following reasons best describes why you have suffered a loss of income? Workplace damaged or destroyed I am unable to get to my usual workplace 52 Is this paid leave? 53 Have you returned to work after the disaster? Date you returned to work after the disaster 54 Do you have an income protection policy? Go to 58 Name of insurance company Cancelled bookings/orders Cancellation of planned tourism events Loss and/or damage to stock Injury suffered Loss and/or damage of machinery/tools Loss of necessary utilities Lack of staff/workers/contractors 55 Have you lodged a claim or intend to lodge a claim for the loss of income? Go to 57 56 Explain why you have not lodged a claim Unable to import/export products Other Go to 58 48 Explain why you stopped work in further detail te: If you did not stop working as a result of the disaster you may not be eligible for this assistance. 57 What was the outcome of the claim? Pending decision Rejected To be lodged in future Granted Has a waiting period been applied? Waiting period end date 49 Are you on planned leave from your workplace? Go to 53 50 What type of leave? For example: annual leave, sick leave, maternity. 51 Start date of leave period End date of leave period 5 of 11 Have payments commenced? Attach a copy of the most recent letter or statement from the insurance policy provider showing payment details. Any income you receive from this insurance policy must be included at question 69. 58 Do you have an interest in any real estate in and/or outside Australia (other than your principal place of residence)? Go to 60

59 Do you receive an income from the properties (i.e. rental/lease income)? Attach a copy of your tax return for the previous year when lodging this claim. 61 Do you own any shares, options or rights in PUBLIC companies NOT Listed on a stock exchange? Do NOT include: managed investments investments purchased with a margin loan. The income you receive from rental properties must be included at question 65 and question 69. 60 Do you own any shares, options, rights, convertible notes or other securities LISTED on an Australian Stock Exchange (e.g. ASX, NSX, APX or Chi-X) or a stock exchange outside Australia? Attach the latest statement detailing your share holding for each company (if available). The income you receive from these investments must be included at question 65 and question 69. Include shares traded in exempt stock markets. Do NOT include: managed investments investments purchased with a margin loan. 1 Name of company Attach the latest statement for each share holding. The income you receive from these investments must be included at question 65 and question 69. 1 Name of company Type of shares, options or rights Number of shares, options or rights Current market value Number of shares or other securities Security code (if known) If you have more than 1 investment, attach a separate sheet with details. Country if not Australia If you have more than 1 investment, attach a separate sheet with details. 6 of 11

62 Do you have any managed investments in and/or outside Australia? Include: investment trusts personal investment plans life insurance bonds friendly society bonds. Do NOT include: conventional life insurance policies investments purchased with a margin loan. APIR code is commonly used by fund managers to identify individual financial products. 1 Attach a document which gives details (e.g. certificate with number of units or account balance) for each investment. The income you receive from these investments must be included at question 65 and question 69. Name of company 63 Please read this before answering the following question. An income stream product is a regular series of payments which may be made for a lifetime or a fixed period by: a financial institution a retirement savings account a superannuation fund a Self Managed Superannuation Fund (SMSF) a Small APRA Fund (SAF). Types of income streams include: account-based pension (also known as allocated pension) market-linked pension (also known as term allocated pension) annuities defined benefit pension (e.g. ComSuper pension, State Super pension) superannuation pension (non-defined benefit). Do you receive income from any income stream products? You will need to obtain a schedule from your product provider for each income stream product. Name of product (e.g. investment trust) Type of product/option (e.g. balanced, growth) The income you receive from income stream products must be included at question 65 and question 69. Number of units APIR code (if known) 1 Name of product provider/smsf/saf Current market value Currency if not AUD Type of income stream Product reference number If you have more than 1 managed investment, attach a separate sheet with details. If you have more than 1 income stream, attach a separate sheet with details. 7 of 11

64 Do you have any money invested in, or do you receive income from, any other investments or sources, not declared elsewhere on this form? Include: all investments from outside Australia (including superannuation) not declared elsewhere on this form. Do NOT include: income from real estate in or outside Australia, private trusts, private companies or business social security payments an account used exclusively for funding from the National Disability Insurance Scheme. 1 You will need to provide proof of your income from other investments and sources. The income you receive from these investments or sources must be included at question 65 and question 69. Type of investment/income 65 What was your gross income for the 8 weeks immediately before the disaster? Gross income is the amount of income you earn before any deductions are taken out (e.g. tax). Include income from all sources, this includes income from employment, income protection policies, shares, investments, real estate income, superannuation, self-employment, holiday pay, commission work etc. Attach verification documents to confirm your income (e.g. payslips, tax returns, BAS statements or a letter from your employer). Source of income Amount Name of organisation/company Total for 8 week period Currency if not AUD If you have more than 1 other investment or source of income, attach a separate sheet with details. If you have more than 7 sources of income, attach a separate sheet with details. 66 If the disaster had not occurred, would your income have continued at the same fortnightly amount in the 13 weeks following your loss of income as it was before the disaster? Go to 69 67 Did you expect your income to: Tick ONE only Decrease Increase 68 How much did you expect to earn each fortnight on average for the 13 weeks after the disaster? per fortnight You will only need to provide proof of the expected increase in income (e.g. contract documents). 8 of 11

69 In the 14 days following your loss of income, did you receive, or are you entitled to receive, any income from any source? Gross income is the amount of income you earn before any deductions are taken out (e.g. tax). Include income from employment, income protection policies, shares, investments, real estate income, superannuation, self-employment, holiday pay, commission work etc. 70 Do you have any accounts in banks, building societies, credit unions or church and charitable development funds? Do NOT include an account used exclusively for funding from the National Disability Insurance Scheme bank accounts held in trust, or private companies. You will need to provide proof of your income. 1 Name of bank, building society or credit union Source of income Amount Type of account Branch number (BSB) Account number (this may not be your card number) Total If you have more than 5 sources of income, attach a separate sheet with details. Balance 2 Name of bank, building society or credit union Type of account Branch number (BSB) Account number (this may not be your card number) Balance If you have more than 2 accounts, attach a separate sheet with details. 71 Do you have any cash? How much cash do you have? 9 of 11

72 Please read this before answering the following questions. You are not breaking the law if you do not give us your tax file number, but if you do not provide it to us, or authorise us to get it from the Australian Taxation Office, you may not be paid. In giving us your tax file number in relation to this claim you authorise us to use your tax file number for other social security payments and services in future where necessary. Have you given us your tax file number before? t sure Go to 74 73 Do you have a tax file number? Please call us on 180 22 66. Your tax file number 74 Please read this before answering the following question. Disaster Recovery Allowance is a taxable payment. If your only income for this financial year is the payment you are now claiming, you may not have to pay any tax. However, you may have to pay tax if you get any other income this financial year, such as salary or wages. If you think you will have to pay tax this year, you can ask us to deduct tax instalments from your payment. You can change this at any time. If you are not sure how much tax to have taken out of your payment, contact the Australian Taxation Office. Do you want tax taken out of your payment? Enter the amount OR percentage of tax you want taken out from each payment. Amount (must be in whole dollars).00 per payment OR Percentage () of taxable payment per payment 76 77 Would you like a Centrelink social worker to contact you? Checklist What number would you like to be contacted on? ( ) Please tick what information has been provided with the claim. If verification documentation is not provided with this claim it will need to be provided within 14 days. All questions on this claim have been completed Proof of identity that add up to the value of 50 points (refer to the factsheet for acceptable forms and point value of documents) Passport or visa details (if not an Australian citizen) (if you answered at question 26) Copy of your tax return for the previous year (if you answered at question 59) The latest statement or document for each investment (if you answered at question 60, 61 or 62) A schedule from your product provider for each income stream (if you answered at question 63) Proof of income from investments or other sources (if you answered at question 64) Proof of income before the disaster (if required at question 65) Proof of expected increased income (if required at question 68) Proof of income for the 14 days following your loss of income (if you answered at question 69) 75 Where do you want your payment made? The bank, building society or credit union account must be in your name. A joint account is acceptable. I do not have a bank, building society or credit union account The account nominated below Name of bank, building society or credit union Branch where your account is held Branch number (BSB) Account number (this may not be your card number) Account held in the name(s) of We will contact you to discuss 10 of 11

78 IMPORTANT INFORMATION Privacy and your personal information Your personal information is protected by law, including the Privacy Act 1988, and is collected by the Australian Government Department of Human Services for the assessment and administration of payments and services. This information is required to process your application or claim. Human Services may disclose your information to Commonwealth departments, other persons, bodies or agencies ONLY where you have provided consent or it is required or authorised by law. Human Services may disclose limited personal information about you to individuals when your circumstances affect their entitlement to payments and services. Your information may be disclosed to the Attorney-General s Department, the Department of Immigration and Border Protection and their service providers, or as authorised or required by law. Relevant information may be given to Australian and State Government Departments and Agencies who are involved in the joint administration of this disaster. Your information may be used by the department or given to other parties for the purposes of research, investigation or where you have agreed or it is required or authorised by law. You can get more information including our privacy policy at www. humanservices.gov.au/privacy or by requesting a copy from the department. Office Use only CSO Logon ID POI type Serial number Issue date State of issue POI type Serial number Issue date State of issue Expiry date Country of issue Expiry date Country of issue 79 Statement I declare that: the information I have provided in this form is complete and correct. I have read the privacy notice above. I understand that: giving false or misleading information is a serious offence. the Australian Government Department of Human Services can make relevant enquiries to make sure I receive the correct entitlement. the Australian Government Department of Human Services may request evidence to support any claims made on this form. I must tell the Australian Government Department of Human Services of any changes to this information within 14 days. any overpayment will be recovered. POI type Serial number Issue date State of issue POI type Expiry date Country of issue Your signature Serial number Issue date Expiry date Date State of issue Country of issue Original document sighted and returned 11 of 11