Centrelink Form SY041 - Verification of your family circumstances: Unreasonable to live at home Instructions
This form contains 101 fields organized into 26 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Alternative Contact Person Details | ||
| No | Checkbox |
Check this box if there is no other person who can provide information about your family situation.
|
| Yes | Checkbox |
Check this box if there is another person who can provide information about your family situation.
|
| Additional Details | Text |
Provide any additional details regarding the alternative contact person.
|
| Person's Name | Text |
Enter the full name of the alternative contact person. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Relationship to You | Text |
Enter the alternative contact person's relationship to you. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Address Line 1 | Text |
Enter the first line of the alternative contact person's address. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Address Line 2 | Text |
Enter the second line of the alternative contact person's address. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Address Line 3 | Text |
Enter the third line of the alternative contact person's address. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Postcode | Text |
Enter the postcode of the alternative contact person's address. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Phone Number Area Code | Text |
Enter the area code part of the alternative contact person's phone number. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Phone Number Local Number | Text |
Enter the local number part of the alternative contact person's phone number. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Authorisation for another person to enquire | ||
| No | Checkbox |
Check this box if you do not want another person or organisation to enquire or act on your behalf when dealing with us.
|
| DummyCalcQ19 | Text | |
| Yes | Checkbox |
Check this box if you want another person or organisation to enquire or act on your behalf when dealing with us.
|
| Centrelink Reference Number | ||
| Centrelink Reference Number (CRN) | Text | |
| Centrelink Reference Number (CRN) | Text | |
| CRN Part 3 | Text |
Please enter the third section of your Centrelink Reference Number.
|
| CRN Part 4 | Text |
Please enter the fourth section of your Centrelink Reference Number.
|
| Child Protection Agency Involvement Details | ||
| No | Checkbox |
Check this box if you or your family have never been involved with a state or territory Child Protection Agency.
|
| Yes | Checkbox |
Check this box if you or your family have been involved with a state or territory Child Protection Agency.
|
| Verification Attachment Details | Text |
Provide any brief details or reference number related to the attached verification of child protection agency involvement. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Child Protection Agency Involvement Details | Text |
Provide detailed information about your or your family's involvement with a state or territory Child Protection Agency. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Contact Details | ||
| Daytime Phone Area Code | Text |
Please provide the area code for your daytime phone number.
|
| Daytime Phone Number | Text |
Please provide the main part of your daytime phone number.
|
| Mobile Phone Number | Text |
Please provide your mobile phone number.
|
| Current Address | ||
| Current Address Line 1 | Text |
Please provide the first line of your current residential address, including street number and street name.
|
| Current Address Line 2 | Text |
Please provide any additional current address details, such as unit number, building name, suburb, or state.
|
| Current Postcode | Number |
Please provide the postcode for your current residential address.
|
| Date of Birth | ||
| Day of Birth | Text |
Provide the day of your birth.
|
| Declaration Signature and Date | ||
| Signature | Text |
Please provide your signature to declare that the information in the form is complete and correct.
|
| Date Signed | Date |
Please provide the date you signed the declaration.
|
| Expected Arrangement Duration | ||
| Emergency/short term | Checkbox |
Check this box if you expect to live in this arrangement for an emergency or a short period.
|
| Long term | Checkbox |
Check this box if you expect to live in this arrangement for a long period.
|
| Not sure | Checkbox |
Check this box if you are not sure how long you expect to live in this arrangement.
|
| Financial Support Details | ||
| No | Checkbox |
Check this box if you do not receive money or other support from your parent(s), guardian, another person, or a government department.
|
| Yes | Checkbox |
Check this box if you do receive money or other support from your parent(s), guardian, another person, or a government department.
|
| Nature of Support | Text |
Enter the type or nature of financial or other support received.
|
| Support Description | Text |
Provide a detailed description of the financial or other support received, including its source and purpose. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Full Name | ||
| Full Name | Text |
Please provide your full legal name.
|
| General | ||
| Instructions | Button | |
| Q5_Details.Address1 | Text | |
| Q5_Details.Address2 | Text | |
| Q9GoToQ12 | Button | |
| Q10_Details.Address1 | Text | |
| Q10_Details.Address2 | Text | |
| Q19GoToQ20 | Button | |
| Button | ||
| Clear | Button | |
| Important Information Acknowledgement | ||
| Q20 | Text | |
| Living Arrangement | ||
| Partner | Checkbox |
Check this box if you live with a partner, whether married, in a registered relationship, or in a de facto relationship (opposite-sex or same-sex).
|
| Friends | Checkbox |
Check this box if you live with friends.
|
| In a refuge | Checkbox |
Check this box if you are currently living in a refuge.
|
| Alone | Checkbox |
Check this box if you live alone.
|
| Other | Checkbox |
Check this box if your living arrangement is not covered by the other options and then provide details below.
|
| Other Living Arrangement Details | Text |
Please provide details about your 'Other' living arrangement.
|
| Living Arrangement Duration Details | Text |
Please provide further details about how long you expect to live in this arrangement. Fill only if 'Other' is 'Yes'.
Depends on:
Other
|
| Other Parent/Guardian Details | ||
| Other Parent/Guardian Name | Text |
Enter the full name of the other parent or guardian. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Other Parent/Guardian Address Line 1 | Text |
Provide the first line of the other parent or guardian's residential address. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Other Parent/Guardian Address Line 2 | Text |
Provide the second line of the other parent or guardian's residential address. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Other Parent/Guardian Address Line 3 | Text |
Provide the third line of the other parent or guardian's residential address, typically the suburb or city. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Other Parent/Guardian Postcode | Text |
Enter the postcode of the other parent or guardian's residential address. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Other Parent/Guardian Phone Area Code | Text |
Enter the area code for the other parent or guardian's contact phone number. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Other Parent/Guardian Phone Number | Text |
Enter the main part of the other parent or guardian's contact phone number. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Mother | Checkbox |
Check this box if the other parent/guardian is your mother. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Father | Checkbox |
Check this box if the other parent/guardian is your father. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Guardian | Checkbox |
Check this box if the other parent/guardian is your guardian. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Parent/Guardian Contact Question | ||
| No | Checkbox |
Check this box if you have NOT had contact with your parent/guardian in the last 2 years.
|
| DummyCalcQ9 | Text | |
| Yes | Checkbox |
Check this box if you HAVE had contact with your parent/guardian in the last 2 years.
|
| Parent/Guardian Details | ||
| Parent/Guardian Name | Text |
Please enter the full name of your parent or guardian as it appears on official documents. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Parent/Guardian Address Line 1 | Text |
Please enter the street number, street name, and any unit or apartment number for your parent or guardian's address. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Parent/Guardian Address Line 2 | Text |
Please enter the suburb and state for your parent or guardian's address. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Parent/Guardian Postcode | Text |
Please enter the postcode for your parent or guardian's address. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Parent/Guardian Phone Number Prefix | Text |
Please enter the area code or prefix of your parent or guardian's contact phone number. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Parent/Guardian Phone Number | Text |
Please enter the main part of your parent or guardian's contact phone number. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Mother | Checkbox |
Check this box if the listed individual is your mother. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Father | Checkbox |
Check this box if the listed individual is your father. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Guardian | Checkbox |
Check this box if the listed individual is your legal guardian. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Payment Account Details | ||
| Bank/Building Society/Credit Union Name | Text |
Provide the full name of the bank, building society, or credit union where the account is held.
|
| Branch Location | Text |
Enter the name or location of the branch where your account is held.
|
| BSB (Branch Number) | Text |
Provide the Branch State Bank (BSB) number for the account.
|
| Account Number | Text |
Enter your bank account number; this may not be your card number.
|
| Account Holders Name(s) | Text |
State the full name(s) under which the bank account is held.
|
| Permission to contact Child Protection Agency | ||
| No, do not contact Child Protection Agency | Checkbox |
Check this box if you do not give permission for us to talk to the state/territory Child Protection Agency about your family situation.
|
| Yes, contact Child Protection Agency | Checkbox |
Check this box if you give permission for us to talk to the state/territory Child Protection Agency about your family situation.
|
| Permission to contact person from question 10 | ||
| No | Checkbox |
Check this box if you do not give permission for us to talk to the person identified at question 10. Fill only if 'In the last 2 years, have you had contact with your parent/guardian?' is 'Yes'.
Depends on:
Yes
|
| Yes | Checkbox |
Check this box if you give permission for us to talk to the person identified at question 10. Fill only if 'In the last 2 years, have you had contact with your parent/guardian?' is 'Yes'.
Depends on:
Yes
|
| Permission to contact person from question 11 | ||
| Q13b_No | CheckBox | |
| Q13b | CheckBox | |
| Reason for not living with parents | ||
| Reason for Not Living with Parents | Text |
Explain in detail why it is unreasonable for you to live with your parents or why you cannot live at home with them.
|
| Responsible Person Details | ||
| Responsible Person's Name | Text |
Enter the full name of the person responsible for looking after you. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Responsible Person's Address Line 1 | Text |
Enter the first line of the responsible person's address. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Responsible Person's Address Line 2 | Text |
Enter the second line of the responsible person's address. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Responsible Person's Address Line 3 | Text |
Enter the third line of the responsible person's address. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Responsible Person's Postcode | Text |
Enter the postcode of the responsible person's address. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Responsible Person Inquiry | ||
| No | Checkbox |
Check this box if no one other than your parents is responsible for looking after you.
|
| Yes | Checkbox |
Check this box if someone other than your parents is responsible for looking after you.
|
| DummyCalcQ12 | Text | |
| Start Date at Address | ||
| Start Date | Date |
Provide the date when you started living at your current address.
|
| Statement Dates | ||
| Date Statements Issued | Date |
Provide the date when the statements were given to the customer for completion.
|
| Statements Return Date | Date |
Provide the date by which the form and statements should be returned to a service centre.
|