Relationship Details outside Australia

Relationship Details outside Australia Your Centrelink Reference Number Return this form to the Department of Human Services International Services by How do we assess your relationship? If you cannot answer the questions Definition of a partner For more information The Australian Government Department of Human Services will assess your relationship based on the following 5 factors: financial arrangements nature of the household social aspects of the relationship presence or absence of sexual relationship nature of commitment. We are collecting information on this form that will be used to decide if you can get payment as a single person. It is important that you answer all the questions and give as much detail as you can. If you are unable to give any of the information asked for, please say so on the form. There are penalties for giving false or misleading information. For our purposes a person is considered to be your partner if you and the person are living together, or usually live together, and are married, or in a registered relationship (opposite-sex or same-sex), or in a de facto relationship (opposite-sex or same-sex). We consider a person to be in a de facto relationship from the time they commence living with another person as a member of a couple. We recognise all couples, opposite-sex and same-sex. Call the Department of Human Services on +61 3 6222 3455. You can call the Department of Human Services between 08.00 am and 5.00 pm (Hobart Time), Monday to Friday. Outside of these times, you will be able to leave a message with our answering service and we will return your call. Please leave your name, your Centrelink Reference Number (CRN), and your telephone number (including country and area codes). te: Call charges apply calls from mobile phones may be charged at a higher rate. You can write to us by: mail at: Department of Human Services International Services PO Box 7809 CANBERRA BC ACT 2610 Australia fax to: +61 3 6222 2799 Please include your phone number (including country and area code), so we can quickly respond to your query. Information online If you would like further information on Centrelink services and payments, you can go to our website www.humanservices.gov.au 1 of 13

What else you will need to provide Filling in this form Returning your form This form tells you which other documents you need to provide. 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 skip to the question number shown. You do not need to answer the questions in between. Check that you have answered all the questions you need to answer and that you have signed and dated this form. If you provide original documents, we will copy your documents and return the originals to you by registered post. The authority to collect this information is contained in social security law. Under Section 192 of the Social Security Administration Act, you are required to complete this form and return it to the Department of Human Services, International Services within 28 days from the day this form was given to you. 2 of 13

1 Other person s name 9 Do you know what address the other person is living at when they are not at your address? Some questions on this form are about your relationship with this person. Where the words the other person appear, they refer to the abovenamed person. 2 3 Have you been married to or been in registered relationship or in a de facto relationship with the other person? Your name Mr Mrs Miss Ms Other Family name Do not complete this form. Call the Department of Human Services, International Services on +61 3 6222 3455. 10 Has the other person left permanently or do you expect them to return to live with you? Left permanently You do not need to fill in the remainder of the form except the signature and date (question 89) on page 12. Expected to return Expected date of return First given name t sure Second given name 11 Why did you start sharing accommodation with the other person? 4 Your permanent address 12 When did you and the other person FIRST start sharing at your CURRENT address? 5 Is the other person the partner of anyone else in the household? Full name of other person s partner 13 Have you shared accommodation continuously since that date? Go to 15 14 For what reasons were you living at separate addresses? 6 Is the other person staying at your address ALL the time? Go to 11 7 Is the other person regularly staying at your address, any number of nights per week or using your home as a base? Go to 10 8 What date did the person leave? CLK0AUS203 1402 3 of 13

15 How long do you intend to share accommodation with the other person? Under 1 month 1 to 3 months 4 to 6 months 18 Is the place where you live jointly owned with the other person? Who pays any rates or fees due to your local council or municipal authority? More than 6 months How long? Who pays for the provision of water and other essential services? 16 Have you ever lived at another address with the other person? Give address/es and dates 19 Is the place where you live still being paid off? Go to 29 Name and address of the bank or finance company 1 Address From To What are the total mortgage repayments? per month 2 Address Currency How much of this do YOU pay? per month Currency From To Go to 29 Attach your latest loan account statement. If you have more than 2 previous addresses, attach a separate sheet with details. 20 Do you pay for your accommodation at your address? Go to 23 17 Do you own the place where you live (including paying it off)? Go to 20 21 How much do you pay and how often? per Currency 4 of 13

22 Name and address of the person/business you pay your accommodation payment to? 27 Since you have indicated that you do not own your own home and you do not pay for your accommodation, give details about why you do not pay for your accommodation. 23 Does anyone else (including the other person) pay or contribute towards accommodation at your address? Go to 26 28 Do you, or have you, previously had people living or staying in your home who pay or have paid YOU for their accommodation? Give the names of those people 24 How much does each person pay and how often? 1 Currency per 29 Does the other person pay for their accommodation at any other address? 2 per Currency 3 Currency per 30 Does the place where you live have more than one living area such as a granny flat, caravan or converted garage? Go to 32 25 Name and address of the person/business they pay their accommodation payment to? What type of living area? Tick ALL that apply Granny flat Caravan Converted garage Other Provide proof (if available) such as documents relating to structural changes in the home (e.g. council approvals, building permits). 26 Is there or has there ever been, a tenancy agreement (lease) for the rent at this address? Go to 28 You need to attach a full copy of your signed lease or tenancy agreement. 31 Do you or the other person live in one of these areas? 5 of 13

32 Do you and the other person eat meals together? 39 Have you ever claimed you and the other person were a member of a couple when you were not? Give details including the dates of when you claimed 33 Do you and the other person use the same kitchen? What are your arrangements for sharing the kitchen? 40 To what extent does the other person provide care, support or help to you in any of the following circumstances? Illness 34 Do you and the other person use the same laundry and bathroom? What are the arrangements for sharing these facilities? Personal crisis 35 Do you and the other person use the same bedroom? Money matters What are your arrangements for sharing the bedroom? Family disputes 36 Are there any other rooms or areas of the home that are for your sole use and not shared with the other person? Describe the areas 41 Do you and the other person go on holidays together? How often is it just the two of you? 37 Please read this before answering the following questions. It is a requirement under Australian social security law that we ask the following questions as one of the considerations for assessing relationship status. How often is it with other adults/children (if applicable)? Do you have a sexual relationship with the other person? Go to 39 38 Have you ever had a sexual relationship with the other person? 6 of 13

42 Do relatives, friends or regular associates consider your relationship with the other person as similar to that of a married, registered or de facto couple? Why 46 Have you ever claimed the other person as a dependant for taxation purposes? In which years? Was this as a dependent spouse or as a housekeeper? Tick ALL that apply Dependent spouse Housekeeper 43 Do they invite you and the other person out as a couple? 47 Do you have a joint bank or giro account, or the use of any bank or giro accounts (including store cards and/or credit cards) with the other person? 44 Do you share social and leisure activities with the other person (e.g. sporting events, family occasions, movies or other activities)? 1 Which organisation are these accounts with? Name of bank, building society, credit union or store What sort of activity and how often? Branch where your account is held 2 Name of bank, building society, credit union or store 45 Is the other person employed? Branch where your account is held Give details of the other person s employer Employer s name 3 Name of bank, building society, credit union or store Address Branch where your account is held If you have more than three joint accounts, attach a separate sheet with details. Phone number (including country and area codes) ( ) Area code ( ) Who has the other person s employer been told to contact in an emergency? 48 49 Do you have access to each other s accounts? Go to 50 Do you both use each other s accounts? What use do you make of this? 7 of 13

50 Are you authorised to use a store card or credit card which operates on an account in the name of the other person? Give the account name 54 Give information about the payment of the following bills. Telephone: Do you share the payment of either a land line or mobile phone with the other person? 1 Account name Who pays it? 2 Account name What is the arrangement for sharing the payment? 3 Account name Name of the telephone company If there are more than 3 accounts, attach a separate sheet with details. Electricity: Do you share the payment with the other person? Who pays it? 51 Do you use the other person s card/s? What is the arrangement for sharing the payment? 52 Is the other person authorised to use a store card or credit card which operates on an account in your name? Give the account name 1 Account name Name of the electricity company Gas: Do you share the payment with the other person? Who pays it? 2 Account name What is the arrangement for sharing the payment? 3 Account name Name of the gas company 53 If there are more than 3 accounts, attach a separate sheet with details. Does the other person use your card/s? Attach a copy of the most recent bills if you still have them. This will make it easier for us to process the form. 55 Are you, or have you ever been, guarantor for one another? Who was the guarantor? Date of guarantee 8 of 13

56 Do you and the other person have any outstanding joint debts on credit cards? 60 Do you and the other person have any outstanding joint debts on rental purchase plans? Who do you owe the debt to? Who do you owe the debt to? What is the date these arrangements were made and why? What is the date these arrangements were made and why? 57 Do you and the other person have any outstanding joint debts on hire purchase? 61 Do you and the other person have any outstanding joint debts for any other item/s? Who do you owe the debt to? Describe this debt What is the date these arrangements were made and why? Who do you owe the debt to? 58 Do you and the other person have any outstanding joint debts on store accounts? What is the date these arrangements were made and why? Who do you owe the debt to? 62 What are the arrangements for paying food and housekeeping items for this household? Who pays? What is the date these arrangements were made and why? Who does the shopping? 59 Do you and the other person have any outstanding joint debts on personal loans? Who do you owe the debt to? What is the date these arrangements were made and why? 9 of 13

63 Do you or the other person own a car or cars? 64 Car 1 In whose name is it registered? Registration number When was the vehicle purchased? Do you share the use of the car? Your share Other person s share Have you and the other person purchased, or are you paying off any of the following items together? Car Caravan Furniture Household appliances and electrical items Other % % Who is responsible for the running costs? I am The other person is We both are Other party is Who? 65 Have you made any arrangements about the household goods you keep should either of you move out? Car 2 In whose name is it registered? Registration number When was the vehicle purchased? Do you share the use of the car? Your share Other person s share % % Who is responsible for the running costs? I am The other person is 66 Is the other person covered by any private medical insurance you have? Name of insurer We both are Other party is Who? Since when? If you have more than 2 cars, attach a separate sheet with details. Why do you hold this medical insurance jointly? 10 of 13

67 Are you covered by any private medical insurance that the other person has? 74 Give details of those children. Show parent's or adoptive parent's names. Since when? Child 1 Family name First given name Why do you hold this medical insurance jointly? Second given name Date of birth Male Female 68 Do you hold any other insurance policies jointly? Parent's name Parent's name Child 2 Family name First given name 69 Is the other person nominated as a beneficiary under your will? I do not have a will Go to 71 Go to 71 Second given name Date of birth Male Female 70 Was the other person previously a beneficiary? On what date was the will changed Parent's name Parent's name 71 Is the other person nominated as a beneficiary under your superannuation? I do not have superannuation Child 3 Family name First given name Second given name 72 Is the other person nominated as a beneficiary under your life insurance? I do not have life insurance Date of birth Parent's name Male Female 73 Are there any children regularly living or staying at your address? Do not answer questions 74 to 80. Go to 81. Parent's name If there are more than 3 children who regularly live or stay at your address, attach a separate sheet with details. 11 of 13

75 Does the other person look after the children? 81 In your opinion, how does your relationship with the other person differ from that of a married, registered or de facto couple? 76 Does the other person help decide matters about the education and development of the children? 77 What family name do the children use at school/day care? 78 Who are listed as contacts in the event of an emergency for the children for school/day care purposes? 82 Is there anything further which is relevant to whether you are living as a member of a couple which has not been covered, and you would like to tell us? Emergency contact 1 Name of person Why this person? Emergency contact 2 Name of person Why this person? 79 How often does the other person visit the school/sporting/leisure outings with or on behalf of the children? 80 Does the other person contribute to the financial support of any of the children? 12 of 13

83 Other than close relatives and the person named in question 1, do any additional people live or regularly stay with you, or use your accommodation as a base for working away from home? Go to 85 85 Did someone help you complete this form? Who helped you? Name 84 Give details of each person below. 1 Full Name Why did you need help to complete this form? Age Male Female What is your relationship to this person? When did he/she first stay? Does he/she ever stay away? How often? Address where he/she stays? 2 Full Name Age Male Female What is your relationship to this person? When did he/she first stay? Does he/she ever stay away? How often? Address where he/she stays? 86 Which of the following documents are you providing with this form? Most recent statement for loan account (if you answered at question 19) Copy of signed current lease or tenancy agreement (if you answered at question 26) Proof of structural changes (if you answered at question 30) Copy of most recent bills (if you answered at question 54) 87 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. Your information may be used by the department or given to other parties for the purposes of research, investigation or where you have agreed or it is required or authorised by law. You can get more information about the way in which the Department of Human Services will manage your personal information, including our privacy policy at www. humanservices.gov.au/privacy or by requesting a copy from the department. 88 Statement I declare that: the information provided in this form is complete and correct. I understand that: giving false or misleading information is a serious offence. the Australian Government Department of Human Services can make relevant enquiries to ensure that correct entitlements are received. If I am receiving a payment or benefit from Centrelink, I must notify the Australian Government Department of Human Services of any change(s) to this information within 28 days of the change(s) occurring. Your signature If there are more than 2 people who live or regularly stay with you, attach a separate sheet with details. 13 of 13 Date