Disaster Recovery Allowance South Australia Pinery Bushfire vember 2015 1 Please read this before answering the following questions. The Disaster Recovery Allowance is for people who can demonstrate they have experienced a loss of income as a direct result of a disaster. The Australian Government Department of Human Services will do regulare audits and you may be asked to provide evidence to support your claim. For more information If you are not sure about your claim, or you need more information, including details about the date you need to lodge your claim by, if you will be required to provide documentation to confirm your identity, or other assistance you may be entitled to, please refer to www.humanservices.gov.au/disaster or call us on 180 22 66. 2 Do you need an interpreter when dealing with us? 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. Go to 5 7 8 Do any of the following apply to you? Tick the first option that applies to you 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. ne of the above Do any of the following apply to you? Tick ALL that apply Live in an affected area Suburb You may not be eligible for this assistance. Please call us on 180 22 66. 3 What is your preferred spoken language? Work in the affected area Suburb Derive income from the affected area Suburb 4 What is your preferred written language? 5 Do you have a Centrelink Reference Number? ne of the above You may not be eligible for this assistance. Please call us on 180 22 66. Your Centrelink Reference Number (if known) 9 Have you lost or suffered a reduction in your income as a direct result of the disaster? 6 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)? You may not be eligible for this assistance. Please call us on 180 22 66. 10 Are you 22 years of age or older? You may not be eligible for this assistance. Please call us on 180 22 66. Go to 15 CLK0EM112 151127 1 of 12
11 Please read this before answering the following questions. Questions 11 14 are to be completed ONLY if you are under 22 years of age. 17 Your gender Male Female Are you a parent or have a dependent child in your care? Go to 15 18 Your date of birth 12 What is your estimated income for the current financial year? 19 Your principal place of residence 13 14 Are you wholly or substantially dependent on another person? You are classed as wholly or substantially dependent if you are dependent on another person (except your partner), are not the parent of another person and your income this financial year will be less than 6,403. Are you currently living with your parent(s) or guardian(s)? 20 21 22 Postcode What date did you start living at this address? Was this your principal place of residence during the disaster? Go to 24 What was your principal place of residence during the disaster? 15 Your name Mr Mrs Family name Miss Ms Other Postcode First given name 23 When did you live at this address? From To Second given name 24 Do you have a temporary or postal address? 16 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)? Other name Type of name (e.g. name at birth) Postcode This address is: Tick ONE box only Temporary address Postal address Go to 26 25 What date did you start living at the address given at 24? If you have more than 1 other name, attach a separate sheet with details. 2 of 12
26 IMPORTANT 32 What is your country of citizenship? 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. Australia Other Date you became an Australian citizen Go to 35 Country of citizenship How can we contact you? Phone number ( ) To help us serve you better, please provide your mobile number Mobile phone number 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 www. humanservices.gov.au/em 33 What is your current type of visa? New Zealand passport Go to 36 (special category visa) Permanent Temporary Unknown (e.g. arrived Go to 35 on parent s passport) 27 28 Were you in Australia when the disaster occurred? Go to 29 When did you return to Australia after the disaster? 34 35 Your visa details on arrival Visa sub class Date visa granted Are you subject to an Assurance of Support agreement? A person is not qualified for the Disaster Recovery Allowance and it is not payable if they are subject to an Assurance of Support agreement. 29 Please read this before answering the following questions. 30 To receive the Disaster Recovery Allowance, you must be an Australian resident living permanently in Australia. Permanently means you normally live in Australia on a long-term basis. Holidays or short trips outside Australia would not affect this. For more information on residency, go to www. humanservices.gov.au/residencedescriptions Are you living in Australia permanently? 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). Go to 36 36 What is the name of your Assurer? Please read this before answering the following questions. We need to know if you have lived in any countries other than Australia from birth through to the present. Lived means where you/your family made your home or spent a long period of time it does not include places you visited. 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 31 What is your country of birth? From To 2 Country of residence From To If you require more space, attach a separate sheet with details. 3 of 12
37 Do you have a partner? Go to 47 44 Does your partner live at the same principal place of residence as you? Go to 46 38 Does your partner have a Centrelink Reference Number? Your partner s Centrelink Reference Number (if known) 45 Your partner s principal place of residence 39 Your partner s name Postcode Mr Mrs Family name Miss Ms Other 46 Do you give permission for your partner to discuss details about your claim? First given name 40 Second given name 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)? Other name 47 Do you have dependent children under 16 years of age in your care? te: There are no additional payments for dependent children. If you currently receive Family Tax Benefit you may need to revise your income estimate. Go to 49 48 of your youngest dependent child Child s family name Type of name (e.g. name at birth) Child s given names Other name this child has been known by 41 42 43 If your partner has more than 1 other name, attach a separate sheet with details. Your partner s gender Male Female Your partner s date of birth Date you became partnered Child s date of birth Child s gender Male Are you the principal carer of this child? Female 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? 4 of 12
49 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 52 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 Cancelled bookings/orders Cancellation of planned tourism events Loss and/or damage to stock Phone number ( ) Postcode Injury suffered Loss and/or damage of machinery/tools Loss of necessary utilities Lack of staff/workers/contractors What industry are you employed in? For example: a banana industry should write: Agriculture banana industry a clothes shop assistant should write: Retail clothes. Unable to import/export products Other Is this work Full-time Part-time Seasonal Casual 53 Explain why you stopped work in further detail Other Give details Was your income from this employer impacted as a result of the disaster? te: If you did not stop working as a result of the disaster you may not be eligible for this assistance. If you have more than one employer, attach a separate sheet with details. You must answer questions 49 to 58 for each employer. 50 Are you self-employed? The income you receive from self-employment must be included at question 70 and question 74. 54 Are you on planned leave from your workplace? Go to 58 51 What date did you stop working or first incur a reduction in your income as a result of the disaster? 55 What type of leave? For example: annual leave, sick leave, maternity. 56 Start date of leave period End date of leave period 57 Is this paid leave? 5 of 12
58 Have you returned to work after the disaster? Date you returned to work after the disaster 59 Do you have an income protection policy? Go to 63 Name of insurance company 60 Have you lodged a claim or intend to lodge a claim for the loss of income? Go to 62 61 Explain why you have not lodged a claim 64 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. The income you receive from rental properties must be included at question 70 and question 74. 65 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? Include shares traded in exempt stock markets. Do NOT include: managed investments investments purchased with a margin loan. Attach the latest statement for each share holding. The income you receive from these investments must be included at question 69 and question 73. 1 Name of company Go to 63 62 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 Number of shares or other securities Country if not Australia Security code (if known) Your share If you have more than 1 investment, attach a separate sheet with details. 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 74. 63 Do you have an interest in any real estate in and/or outside Australia (other than your principal place of residence)? Go to 65 6 of 12
66 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. 1 Name of company 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 70 and question 74. 67 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. Type of shares, options or rights Number of shares, options or rights Your share Current market value 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 70 and question 74. Name of company If you have more than 1 investment, attach a separate sheet with details. Name of product (e.g. investment trust) Type of product/option (e.g. balanced, growth) Number of units APIR code (if known) Current market value Currency if not AUD Your share If you have more than 1 managed investment, attach a separate sheet with details. 7 of 12
68 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? 69 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. 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 70 and question 74. You will need to obtain a schedule from your product provider for each income stream product. 1 Type of investment/income The income you receive from income stream products must be included at question 66 and question 70. Name of organisation/company 1 Name of product provider/smsf/saf Currency if not AUD Your share Type of income stream If you have more than 1 other investment or source of income, attach a separate sheet with details. Product reference number Your share If you have more than 1 income stream, attach a separate sheet with details. 8 of 12
70 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 Total for 8 week period Amount 74 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. Source of income You will need to provide proof of your income. Total Amount If you have more than 5 sources of income, attach a separate sheet with details. If you have more than 7 sources of income, attach a separate sheet with details. 71 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 74 72 Did you expect your income to: Tick ONE only Decrease Increase 73 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). 9 of 12
75 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. 1 Name of bank, building society or credit union Type of account You will need to attach proof of bank balance if your bank account balance is greater than 38,700. 77 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 79 78 Do you have a tax file number? Please call us on 180 22 66. Your tax file number Branch number (BSB) Account number (this may not be your card number) Balance Your share 2 Name of bank, building society or credit union Type of account Branch number (BSB) 79 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) Percentage () of taxable payment Account number (this may not be your card number).00 per payment OR per payment Balance Your share If you have more than 2 accounts, attach a separate sheet with details. 76 Do you have any cash on hand? Cash on hand this refers to any cash which you have available that is not used for regular day to day expenses, such as petrol or groceries. How much cash do you have? 10 of 12
80 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. 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 83 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. Relevant information may be given to Australian and State Government Departments and organisations who are involved in the joint administration of this disaster. 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. 81 82 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 30) Copy of the most recent letter or statement from the insurance policy (if you answered at question 62) 84 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. this payment is for people who have a loss of income as a direct result of a disaster. 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. any overpayment will be recovered. Your signature Copy of your tax return for the previous year (if you answered at question 64) The latest statement or document for each investment (if you answered at question 65, 66 or 67) Date A schedule from your product provider for each income stream (if you answered at question 68) Proof of income from investments or other sources (if you answered at question 69) Proof of income before the disaster (if required at question 70) Proof of expected increased income (if required at question 73) Proof of income for the 14 days following your loss of income (if you answered at question 74) Proof of bank balance (if required at question 75) 11 of 12
Office Use only SO Logon ID Identity type Serial number Issue date State of issue Expiry date Country of issue Identity type Serial number Issue date State of issue Expiry date Country of issue Identity type Serial number Issue date State of issue Expiry date Country of issue Identity type Serial number Issue date State of issue Expiry date Country of issue Original document sighted and returned 12 of 12