Claim for Commonwealth Seniors Health Card Instructions

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This form contains 273 fields organized into 62 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name Type Description
Account-Based Pension Income Question
No Checkbox
Check this box if neither you nor your partner receive income from an account-based pension.
Yes Checkbox
Check this box if you or your partner receive income from an account-based pension.
Child Entered Care Status
No Checkbox
Check this box if no child has entered your or your partner's care.
Yes Checkbox
Check this box if any child has entered your or your partner's care.
Number of children Number
Please enter the number of children who have entered your or your partner's care. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Child Left Care Status
Child's Name Text
Please provide the full name of the child who has left your care.
No Checkbox
Check this box if no child has left your or your partner's care.
Yes Checkbox
Check this box if any child has left your or your partner's care.
DummyCalcQ20 Text
Depends on: Yes
Combined Estimated Adjusted Taxable Income
Combined Estimated Adjusted Taxable Income Number
Provide the combined estimated adjusted taxable income for you and your partner, including any deemed income from account-based pensions. Fill only if 'Will your (and your partner's) combined income in the current financial year be the same, higher or lower than it was in the financial year you indicated at question 26?' is 'Lower'.
Depends on: Lower
Combined Total Adjusted Taxable Income
Combined Total Adjusted Taxable Income Number
Enter the combined total adjusted taxable income for you and your partner. Fill only if 'Do you have a partner?' is 'Yes'.
Depends on: Yes
Combined Total Adjusted Taxable Income Status (Question 29)
Below the income limit Checkbox
Check this box if your combined total adjusted taxable income is below the income limit for the Commonwealth Seniors Health Card.
Income Below Limit Status Text
Indicate whether your combined total adjusted taxable income, including deemed income from account-based pensions, is below the income limit for the Commonwealth Seniors Health Card.
Above the income limit Checkbox
Check this box if your combined total adjusted taxable income is above the income limit for the Commonwealth Seniors Health Card.
Combined Total Adjusted Taxable Income Status (Question 30)
Below the income limit Checkbox
Check this box if your combined total adjusted taxable income is below the income limit for the Commonwealth Seniors Health Card.
DummyCalcQ30 Text
Above the income limit Checkbox
Check this box if your combined total adjusted taxable income is above the income limit for the Commonwealth Seniors Health Card.
Current Living Arrangement With Partner
No Checkbox
This box should be checked if you do not currently live in the same home as your partner. Fill only if 'Do you have a partner?' is 'Yes'.
Depends on: Yes
Yes Checkbox
This box should be checked if you currently live in the same home as your partner. Fill only if 'Do you have a partner?' is 'Yes'.
Depends on: Yes
Next Question Number Number
Please provide the number of the next question you should answer if you are not currently living with your partner. Fill only if 'Do you have a partner?' is 'Yes'.
Depends on: Yes
Dependent Child Details Change Status
Not applicable Checkbox
Check this box if question 19 regarding dependent child(ren) and students' details changing is not applicable to your situation.
No Checkbox
Check this box if the details of your dependent child(ren) and students have not changed since you were last granted a Commonwealth Seniors Health Card.
Yes Checkbox
Check this box if the details of your dependent child(ren) and students have changed since you were last granted a Commonwealth Seniors Health Card.
Documents You Are Providing
Identity documents for yourself Checkbox
Check this box if you are providing identity documents for yourself as part of this claim.
Authorising a person or organisation to enquire or act on your behalf (SS313) form Checkbox
Check this box if you are providing the SS313 form to authorise a person or organisation to enquire or act on your behalf, especially if you answered Yes at question 16. Fill only if 'Do you want to authorise another person or organisation to make enquires, get payments and/or act on your behalf?' is 'Yes'.
Depends on: Yes
Original Notice of Assessment or other documents (27A) Checkbox
Check this box if you are providing your Original Notice of Assessment or other documents to verify the amount mentioned in question 27A, if you are not required to lodge a tax return.
Tax return or other documents (27B) Checkbox
Check this box if you are providing your tax return or other documents to verify the amount mentioned in question 27B, if you are not required to lodge a tax return.
Tax return or other documents (27C) Checkbox
Check this box if you are providing your tax return or other documents to verify the amount mentioned in question 27C, if you are not required to lodge a tax return.
Payment summary (27D) Checkbox
Check this box if you are providing your payment summary as mentioned in question 27D.
Payment summary and/or tax return or other documents (27E) Checkbox
Check this box if you are providing your payment summary, tax return, or other documents to verify the amount mentioned in question 27E, if you are not required to lodge a tax return.
A Details of income stream product (SA330) form or a similar schedule Checkbox
Check this box if you are providing a 'Details of income stream product (SA330)' form or a similar schedule, as mentioned in question 28. Fill only if 'Do you (or your partner) receive income from an account-based pension?' is 'Yes'.
Depends on: Yes
Documents to support the reason your income will be lower Checkbox
Check this box if you are providing documents to support the reason your income will be lower, as mentioned in question 31. Fill only if 'Will your (and your partner's) combined income in the current financial year be the same, higher or lower than it was in the financial year you indicated at question 26?' is 'Lower'.
Depends on: Lower
Documents Your Partner Is Providing
Identity documents for yourself Checkbox
Check this box if your partner is providing identity documents, especially if they answered 'Yes' at question 2 and are re-claiming. Fill only if 'Is your partner also claiming the Commonwealth Seniors Health Card?' is 'Yes'.
Depends on: Yes
Authorising a person or organisation to enquire or act on your behalf (SS313) form Checkbox
Check this box if your partner is providing an SS313 form to authorise someone to act on their behalf, particularly if they answered 'Yes' at question 16. Fill only if 'Do you want to authorise another person or organisation to make enquires, get payments and/or act on your behalf?' is 'Yes'.
Depends on: Partner Authorises Other Party
Original Notice of Assessment or other documents to verify this amount (Q27A) Checkbox
Check this box if your partner is providing their Original Notice of Assessment or other documents to verify the amount mentioned in question 27A, especially if they are not required to lodge a tax return.
Tax return or other documents to verify this amount (Q27B) Checkbox
Check this box if your partner is providing their tax return or other documents to verify the amount mentioned in question 27B, especially if they are not required to lodge a tax return.
Tax return or other documents to verify this amount (Q27C) Checkbox
Check this box if your partner is providing their tax return or other documents to verify the amount mentioned in question 27C, especially if they are not required to lodge a tax return.
Payment summary (Q27D) Checkbox
Check this box if your partner is providing a payment summary as mentioned in question 27D.
Payment summary and/or tax return or other documents to verify this amount (Q27E) Checkbox
Check this box if your partner is providing a payment summary, tax return, or other documents to verify the amount mentioned in question 27E, especially if they are not required to lodge a tax return.
A Details of income stream product (SA330) form or a similar schedule (Q28) Checkbox
Check this box if your partner is providing a Details of income stream product (SA330) form or a similar schedule as mentioned in question 28. Fill only if 'Do you (or your partner) receive income from an account-based pension?' is 'Yes'.
Depends on: Yes
Documents to support the reason your income will be lower (Q31) Checkbox
Check this box if your partner is providing documents to support the reason why their income will be lower, as mentioned in question 31. Fill only if 'Will your (and your partner's) combined income in the current financial year be the same, higher or lower than it was in the financial year you indicated at question 26?' is 'Lower'.
Depends on: Lower
Financial Year for Income Details
Financial Year Start Number
Please enter the starting year of the financial year for which you are providing income details.
Max length: 4 characters
Financial Year End Number
Please enter the ending year of the financial year for which you are providing income details.
Max length: 4 characters
First Account-Based Pension Details
Product Provider Name (Line 1) Text
Enter the first line of the product provider's name, SMSF, or SAF for your first account-based pension.
Product Provider Name (Line 2) Text
Enter the second line of the product provider's name, SMSF, or SAF for your first account-based pension. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Product Reference Number Text
Enter the product reference number for your first account-based pension. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Commencement Date Date
Enter the date your first account-based pension commenced. Fill only if 'Yes' is 'Yes'.
Max length: 10 characters
Depends on: Yes
Owned by You Checkbox
Check this box if the first account-based pension is owned by you. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Owned by Your Partner Checkbox
Check this box if the first account-based pension is owned by your partner. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
First Child Who Entered Care Details
First Child's Name Text
Please provide the full name of the first child who entered your care. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
First Child's Date of Birth Date
Please provide the date of birth for the first child who entered your care. Fill only if 'Yes' is 'Yes'.
Max length: 10 characters
Depends on: Yes
First Child Who Left Care Details
First Child's Name Text
Provide the full name of the first child who has left your care. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
First Child's Date of Birth Date
Provide the date of birth for the first child who has left your care. Fill only if 'Yes' is 'Yes'.
Max length: 10 characters
Depends on: Yes
Q22 Text
Max length: 4 characters
DummyCalcQ23 Text
Future Combined Income Status
The same Checkbox
Check this box if your combined income in the current financial year will be the same as it was in the financial year indicated at question 26.
Higher Checkbox
Check this box if your combined income in the current financial year will be higher than it was in the financial year indicated at question 26.
Lower Checkbox
Check this box if your combined income in the current financial year will be lower than it was in the financial year indicated at question 26.
General
Instructions Button
Instructions Button
Q1GoToQ3 Button
Q11GoToQ12A Button
Q11GoToQ12B Button
Q11GoToQ12C Button
Q11GoToQ16A Button
Q11GoToQ16B Button
Q11GoToQ16C Button
Q11GoToQ16D Button
Q12GoToQ15 Button
Q14GoToQ16 Button
Q17YGoToQ19 Button
Q17YPGoToQ19 Button
Q19GoToQ23a Button
Q19GoToQ23b Button
Q23YGoToQ25 Button
Q23YPGoToQ25 Button
Q25 Text
Max length: 1 characters
Q28GoToQ30 Button
Q29GoToQ33 Button
Q29GoToQ31 Button
Q30GoToQ33 Button
Print button Button
Clear button Button
Page 12
Sign Text
Your Signature Date Date
Provide the date when you signed the declaration.
Max length: 10 characters
Your Signature Text
Enter your signature to acknowledge the declaration.
Partner's Signature Date Date
Provide the date when your partner signed the declaration. Fill only if 'Do you have a partner?' is 'Yes'.
Max length: 10 characters
Depends on: Yes
Partner Health Card Claim Inquiry
No Checkbox
Check this box if your partner is not claiming the Commonwealth Seniors Health Card but you will still provide their personal and income details without identity documents. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Yes Checkbox
Check this box if your partner is also claiming the Commonwealth Seniors Health Card, expecting both of you to be eligible for the card. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Partner Status Inquiry
No Checkbox
Check this box if you do not have a partner.
DummyCalcQ1 Text
Yes Checkbox
Check this box if you have a partner.
Partner's Authorisation for Another Person or Organisation
Partner Does Not Authorise Other Party Checkbox
Check this box if your partner does not want to authorise another person or organisation to make enquiries, get payments, or act on their behalf. Fill only if 'Do you have a partner?' is 'Yes'.
Depends on: Yes
Partner Authorises Other Party Checkbox
Check this box if your partner wants to authorise another person or organisation to make enquiries, get payments, or act on their behalf. Fill only if 'Do you have a partner?' is 'Yes'.
Depends on: Yes
Partner's Bank Account Details
Partner's Bank Name Text
Provide the full name of your partner's bank, building society, or credit union. Fill only if 'Partner Yes' is 'Yes'.
Depends on: Partner Yes
Partner's BSB Text
Enter your partner's Branch Number (BSB), which typically identifies the bank and branch where the account is held. Fill only if 'Partner Yes' is 'Yes'.
Max length: 6 characters
Depends on: Partner Yes
Partner's Account Number Text
Enter your partner's bank account number, which may not be the same as their card number. Fill only if 'Partner Yes' is 'Yes'.
Depends on: Partner Yes
Partner's Account Holder Name Text
Provide the full name(s) under which your partner's bank account is registered. Fill only if 'Partner Yes' is 'Yes'.
Depends on: Partner Yes
Partner's Bank Details Provision Consent
Partner No Checkbox
Check this box if your partner does not wish to provide their bank details at this time. Fill only if 'Do you have a partner?' is 'Yes'.
Depends on: Yes
Partner Yes Checkbox
Check this box if your partner wishes to provide their bank details to ensure timely payments. Fill only if 'Do you have a partner?' is 'Yes'.
Depends on: Yes
Partner's Centrelink Reference Number
Partner's Centrelink Reference Number Part 1 Text
Enter the first part of your partner's Centrelink Reference Number, if known. Fill only if 'Yes' is 'Yes'.
Max length: 3 characters
Depends on: Yes
Partner's Centrelink Reference Number Part 2 Text
Enter the second part of your partner's Centrelink Reference Number, if known. Fill only if 'Yes' is 'Yes'.
Max length: 3 characters
Depends on: Yes
Partner's Centrelink Reference Number Part 3 Text
Enter the third part of your partner's Centrelink Reference Number, if known. Fill only if 'Yes' is 'Yes'.
Max length: 3 characters
Depends on: Yes
Partner's Centrelink Reference Number Part 4 Text
Enter the fourth part of your partner's Centrelink Reference Number, if known. Fill only if 'Yes' is 'Yes'.
Max length: 1 characters
Depends on: Yes
Partner's Date of Birth
Partner's Date of Birth Day Date
Enter the day of your partner's date of birth. Fill only if 'Do you have a partner?' is 'Yes'.
Max length: 10 characters
Depends on: Yes
Partner's First Other Name
Partner's Other Name Text
Enter the first other name your partner has been known by. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Partner's Other Name Type Text
Specify the type of the first other name, such as name at birth or previous married name. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Partner's Gender
Male Checkbox
Check this box if your partner identifies as male. Fill only if 'Do you have a partner?' is 'Yes'.
Depends on: Yes
Female Checkbox
Check this box if your partner identifies as female. Fill only if 'Do you have a partner?' is 'Yes'.
Depends on: Yes
Non-binary Checkbox
Check this box if your partner identifies as non-binary. Fill only if 'Do you have a partner?' is 'Yes'.
Depends on: Yes
Partner's Income Details
Partner's Taxable Income (ATO Notice) Number
Enter the partner's taxable income as stated on their original Notice of Assessment from the Australian Taxation Office. Fill only if 'Do you have a partner?' is 'Yes'.
Depends on: Yes
Partner's Taxable Income (Low Income/No Tax Return) Number
Enter the partner's taxable income if they were not required to lodge a tax return due to low income, ensuring it includes only taxable income not from sources B to E. Fill only if 'Do you have a partner?' is 'Yes'.
Depends on: Yes
Partner's Foreign Income Number
Enter the amount of the partner's foreign income on which Australian income tax was not paid, in Australian dollars. Fill only if 'Do you have a partner?' is 'Yes'.
Depends on: Yes
Partner's Total Net Investment Loss Number
Enter the partner's total net investment loss, which includes net rental property losses and net financial investment losses. Fill only if 'Do you have a partner?' is 'Yes'.
Depends on: Yes
Partner's Employer Provided Benefits Number
Enter the total value of the partner's employer-provided benefits, subtracting the first $1,000 from the total. Fill only if 'Do you have a partner?' is 'Yes'.
Depends on: Yes
Partner's Reportable Superannuation Contributions Number
Enter the total amount of the partner's reportable superannuation contributions, including both employer and personal deductible contributions. Fill only if 'Do you have a partner?' is 'Yes'.
Depends on: Yes
Partner's Total Income (Sum A-E) Number
Enter the partner's total income, which is the sum of amounts entered for sections A, B, C, D, and E. Fill only if 'Do you have a partner?' is 'Yes'.
Depends on: Yes
Partner's Name
Q4YP.Title_Mr CheckBox
Depends on: Yes
Mrs Checkbox
Check this box if your partner's title is Mrs. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Miss Checkbox
Check this box if your partner's title is Miss. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Ms Checkbox
Check this box if your partner's title is Ms. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Mx Checkbox
Check this box if your partner's title is Mx. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Q4YP.TitleOther Text
Depends on: Yes
Partner's Family Name Text
Please provide your partner's family name. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Partner's First Given Name Text
Please provide your partner's first given name. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Partner's Second Given Name Text
Please provide your partner's second given name. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Partner's Other Names Declaration
No Checkbox
Check this box if your partner has not been known by any other name(s) and you wish to go to the next question. Fill only if 'Do you have a partner?' is 'Yes'.
Depends on: Yes
Yes Checkbox
Check this box if your partner has been known by any other name(s) and you need to provide further details below. Fill only if 'Do you have a partner?' is 'Yes'.
Depends on: Yes
Partner's Permanent Address
Partner's Address Line 1 Text
Please enter the first line of your partner's permanent residential address. Fill only if 'Do you have a partner?' is 'Yes'.
Depends on: Yes
Partner's Address Line 2 Text
Please enter the second line of your partner's permanent residential address. Fill only if 'Do you have a partner?' is 'Yes'.
Depends on: Yes
Partner's Address Line 3 Text
Please enter the third line of your partner's permanent residential address, including suburb or town. Fill only if 'Do you have a partner?' is 'Yes'.
Depends on: Yes
Partner's Postcode Text
Please enter the postcode of your partner's permanent residential address. Fill only if 'Do you have a partner?' is 'Yes'.
Max length: 4 characters
Depends on: Yes
Partner's Permission for You to Speak on Their Behalf
No Checkbox
Check this box if your partner does not give permission for you to speak with the organization on their behalf. Fill only if 'Do you have a partner?' is 'Yes'.
Depends on: Yes
Yes Checkbox
Check this box if your partner gives permission for you to speak with the organization on their behalf. Fill only if 'Do you have a partner?' is 'Yes'.
Depends on: Yes
Partner's Postal Address
Partner's Postal Address Line 1 Text
Provide the first line of your partner's postal address. Fill only if 'Do you have a partner?' is 'Yes'.
Depends on: Yes
Partner's Postal Address Line 2 Text
Provide the second line of your partner's postal address. Fill only if 'Do you have a partner?' is 'Yes'.
Depends on: Yes
Partner's Postal Address Line 3 Text
Provide the third line of your partner's postal address, typically including suburb, city, or state. Fill only if 'Do you have a partner?' is 'Yes'.
Depends on: Yes
Partner's Postal Postcode Text
Provide your partner's postal postcode. Fill only if 'Do you have a partner?' is 'Yes'.
Max length: 4 characters
Depends on: Yes
Partner's Prior Tax File Number Submission
No Checkbox
Check this box if your partner has not previously given their tax file number. Fill only if 'Do you have a partner?' is 'Yes'.
Depends on: Yes
Not sure Checkbox
Check this box if your partner is unsure whether they have previously given their tax file number. Fill only if 'Do you have a partner?' is 'Yes'.
Depends on: Yes
Yes Checkbox
Check this box if your partner has previously given their tax file number. Fill only if 'Do you have a partner?' is 'Yes'.
Depends on: Yes
Partner's Second Other Name
Partner's Second Other Name Text
Please enter your partner's second other name, if applicable. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Partner's Second Other Name Type Text
Please describe the type of your partner's second other name, for example, 'name before marriage'. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Partner's Tax File Number Details
No Checkbox
Check this box if your partner does not have a tax file number. Fill only if 'No', 'Not sure' is 'No' or 'Not sure' in question 17.
Depends on: No, Not sure
Yes Checkbox
Check this box if your partner does have a tax file number. Fill only if 'No', 'Not sure' is 'No' or 'Not sure' in question 17.
Depends on: No, Not sure
Partner's Tax File Number Part 1 Text
Enter the first part of your partner's tax file number. Fill only if 'Yes' is 'Yes' for question 18.
Max length: 3 characters
Depends on: Yes
Partner's Tax File Number Part 2 Text
Enter the second part of your partner's tax file number. Fill only if 'Yes' is 'Yes' for question 18.
Max length: 3 characters
Depends on: Yes
Partner's Tax File Number Part 3 Text
Enter the third part of your partner's tax file number. Fill only if 'Yes' is 'Yes' for question 18.
Max length: 3 characters
Depends on: Yes
Period Not Living With Partner
Period From Date Date
Provide the date your period of not living with your partner started. Fill only if 'No' is 'No'.
Max length: 10 characters
Depends on: No
Period To Date Date
Provide the date your period of not living with your partner ended, if applicable. Fill only if 'No' is 'No'.
Depends on: No
Indefinite Checkbox
Check this box if the period of not living with your partner is indefinite. Fill only if 'No' is 'No'.
Depends on: No
Go To Page Number Text
Enter the page number or section to navigate to based on the form's instructions. Fill only if 'Do you have a partner?' is 'Yes'.
Depends on: Yes
Reason for Lower Future Income
DummyCalcQ31 Text
Depends on: Lower
Reason for Lower Income Text
Please explain why your income will be lower, providing details such as stopped working, previously sold significant assets, medical expenses, or ceased business operations. Fill only if 'Lower' is selected.
Depends on: Lower
Reason For Not Living With Partner
Partner's illness Checkbox
Check this box if you are not living with your partner because of your partner's illness. Fill only if 'No' is 'No'.
Depends on: No
Your illness Checkbox
Check this box if you are not living with your partner because of your own illness. Fill only if 'No' is 'No'.
Depends on: No
Partner in prison Checkbox
Check this box if you are not living with your partner because your partner is in prison. Fill only if 'No' is 'No'.
Depends on: No
Partner's employment Checkbox
Check this box if you are not living with your partner due to your partner's employment. Fill only if 'No' is 'No'.
Depends on: No
Other reason Checkbox
Check this box if you are not living with your partner for a reason not listed above and provide details in the space provided. Fill only if 'No' is 'No'.
Depends on: No
Other Reason (Brief) Text
Provide brief details for the 'Other' reason why you are not living with your partner. Fill only if 'Do you have a partner?' is 'Yes'.
Depends on: Yes
Detailed Reason for Not Living with Partner Text
Provide a detailed explanation of why you are not living with your partner. Fill only if 'Other reason' is 'Yes'.
Depends on: Other reason
Relationship Status
Married Checkbox
Check this box if your current relationship status is married. Fill only if 'Do you have a partner?' is 'Yes'.
Depends on: Yes
DummyCalcQ11 Text
Date Married or Reconciled Date
Please provide the date you were married or last reconciled with your partner if your current relationship status is married. Fill only if 'Married' is 'Yes'.
Max length: 10 characters
Depends on: Married
Registered relationship Checkbox
Check this box if your relationship is currently registered under Australian state or territory law. Fill only if 'Do you have a partner?' is 'Yes'.
Depends on: Yes
Date Registered or Reconciled Date
Please provide the date your relationship was registered or you last reconciled with your partner if your current relationship status is a registered relationship. Fill only if 'Registered relationship' is 'Yes'.
Max length: 10 characters
Depends on: Registered relationship
De facto Checkbox
Check this box if your relationship is similar to a married couple but you are not married or in a registered relationship. Fill only if 'Do you have a partner?' is 'Yes'.
Depends on: Yes
Date Started or Reconciled (De Facto) Date
Please provide the date you started your de facto relationship or last reconciled with your partner if your current relationship status is de facto. Fill only if 'De facto' is 'Yes'.
Max length: 10 characters
Depends on: De facto
Separated Checkbox
Check this box if you were previously in a marriage, registered, or de facto relationship and are now separated. Fill only if 'Do you have a partner?' is 'Yes'.
Depends on: Yes
Date of Last Separation Date
Please provide the date of your most recent separation if your current relationship status is separated. Fill only if 'Separated' is 'Yes'.
Max length: 10 characters
Depends on: Separated
Divorced Checkbox
Check this box if your current relationship status is divorced. Fill only if 'Do you have a partner?' is 'Yes'.
Depends on: Yes
Date of Divorce Date
Please provide the date your divorce was finalized if your current relationship status is divorced. Fill only if 'Divorced' is 'Yes'.
Max length: 10 characters
Depends on: Divorced
Widowed Checkbox
Check this box if you were previously in a marriage, registered, or de facto relationship and your partner has passed away. Fill only if 'Do you have a partner?' is 'Yes'.
Depends on: Yes
Date of Partner's Death Date
Please provide the date of your partner's death if your current relationship status is widowed. Fill only if 'Widowed' is 'Yes'.
Max length: 10 characters
Depends on: Widowed
Never married or lived with a partner Checkbox
Check this box if you have never been married or lived with a partner. Fill only if 'Do you have a partner?' is 'No'.
Depends on: No
Second Account-Based Pension Details
Product Provider Name (Second Account) Text
Enter the name of the product provider, Self Managed Superannuation Fund (SMSF), or Small APRA Fund (SAF) for the second account-based pension. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Product Reference Number (Second Account) Text
Enter the product reference number for the second account-based pension. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Commencement Date (Second Account) Date
Enter the date the second account-based pension commenced. Fill only if 'Yes' is 'Yes'.
Max length: 10 characters
Depends on: Yes
You Checkbox
Check this box if the second account-based pension is owned by you. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Your partner Checkbox
Check this box if the second account-based pension is owned by your partner. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Second Child Who Entered Care Details
Second Child's Name Text
Please provide the full name of the second child who entered your care. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Second Child's Date of Birth Date
Please provide the date of birth for the second child who entered your care. Fill only if 'Yes' is 'Yes'.
Max length: 10 characters
Depends on: Yes
Second Child Who Left Care Details
Second Child's Name Text
Please enter the full name of the second child who has left care. Fill only if 'Yes' is 'Yes'.
Depends on: Yes
Second Child's Date of Birth Date
Please provide the date of birth for the second child who has left care. Fill only if 'Yes' is 'Yes'.
Max length: 10 characters
Depends on: Yes
Your Authorisation for Another Person or Organisation
No Checkbox
Check this box if you do not want to authorise another person or organisation to make enquiries, get payments and/or act on your behalf.
Yes Checkbox
Check this box if you want to authorise another person or organisation to make enquiries, get payments and/or act on your behalf.
Your Bank Account Details
Bank Name Text
Enter the name of your bank, building society, or credit union. Fill only if 'You - Yes' is 'Yes'.
Depends on: You - Yes
Branch Number (BSB) Text
Enter the branch number (BSB) for your bank account. Fill only if 'You - Yes' is 'Yes'.
Max length: 6 characters
Depends on: You - Yes
Account Number Text
Enter your bank account number. Fill only if 'You - Yes' is 'Yes'.
Depends on: You - Yes
Account Holder Name(s) Text
Enter the full name(s) in which the bank account is held. Fill only if 'You - Yes' is 'Yes'.
Depends on: You - Yes
Your Bank Details Provision Consent
You - No Checkbox
Check this box if you, the applicant, do not wish to provide your bank details at this time.
You - Yes Checkbox
Check this box if you, the applicant, wish to provide your bank details to ensure timely payments.
Your Centrelink Reference Number
Part 1 Text
Please enter the first part of your Centrelink Reference Number.
Max length: 3 characters
Part 2 Text
Please enter the second part of your Centrelink Reference Number.
Max length: 3 characters
Part 3 Text
Please enter the third part of your Centrelink Reference Number.
Max length: 3 characters
Part 4 Text
Please enter the fourth and final part of your Centrelink Reference Number.
Max length: 1 characters
Your Contact Details
Home Phone Number Text
Enter your primary home phone number.
Max length: 10 characters
No Checkbox
The user should check this box if their home phone number is not a silent number.
Yes Checkbox
The user should check this box if their home phone number is a silent number.
Mobile Phone Number Text
Enter your mobile phone number.
Max length: 10 characters
Fax Number Text
Enter your fax number.
Max length: 10 characters
Work Phone Number Text
Enter your work phone number.
Max length: 10 characters
Alternative Phone Number Text
Enter an alternative phone number where you can be contacted.
Max length: 10 characters
Email Address Text
Enter your email address.
Your Date of Birth
Your Date of Birth Date
Please enter your date of birth.
Max length: 10 characters
Your First Other Name
First Other Name Text
Please provide the first other name you have been known by, such as a name at birth, name before marriage, previous married name, Aboriginal or skin name, alias, adoptive name, or foster name. Fill only if 'Yes (You)' is 'Yes'.
Depends on: Yes (You)
Type of First Other Name Text
Please specify the type of the first other name provided, for example, name at birth or name before marriage. Fill only if 'Yes (You)' is 'Yes'.
Depends on: Yes (You)
Your Gender
Male Checkbox
Check this box if your gender is male.
Female Checkbox
Check this box if your gender is female.
Non-binary Checkbox
Check this box if your gender is non-binary.
Your Income Details
Your Taxable Income Number
Enter your taxable income as per your original Notice of Assessment issued by the Australian Taxation Office.
Your Alternative Taxable Income Number
Enter your taxable income if your income was too low and you were not required to lodge a tax return.
Your Foreign Income Number
Enter the amount of foreign income you received on which you did not pay Australian income tax, in Australian dollars.
Your Total Net Investment Loss Number
Enter your total net investment loss, which includes net rental property losses and net financial investment losses.
Your Employer Provided Benefits Number
Enter the total amount of your employer provided benefits exceeding $1,000.
Your Reportable Super Contributions Number
Enter the sum of your reportable employer superannuation contributions and personal deductible superannuation contributions.
Your Total Income Number
Enter your total income, calculated as the sum of taxable income, foreign income, total net investment loss, employer provided benefits, and reportable superannuation contributions.
Estimated Taxable Income Number
Enter the estimated taxable income you expect to receive in the current financial year. Fill only if 'Will your (and your partner's) combined income in the current financial year be the same, higher or lower than it was in the financial year you indicated at question 26?' is 'Lower'.
Depends on: Lower
Estimated Taxable Income (Low Income) Number
Enter the amount of income you expect to receive if your income is too low and you are not required to lodge a tax return. Fill only if 'Will your (and your partner's) combined income in the current financial year be the same, higher or lower than it was in the financial year you indicated at question 26?' is 'Lower'.
Depends on: Lower
Foreign Income (You) Number
Enter the amount of foreign income you received on which you do not pay Australian income tax. Fill only if 'Will your (and your partner's) combined income in the current financial year be the same, higher or lower than it was in the financial year you indicated at question 26?' is 'Lower'.
Depends on: Lower
Total Net Investment Loss (You) Number
Enter your total net investment loss, which includes net rental property losses and net financial investment losses. Fill only if 'Will your (and your partner's) combined income in the current financial year be the same, higher or lower than it was in the financial year you indicated at question 26?' is 'Lower'.
Depends on: Lower
Employer Provided Benefits (You) Number
Enter the total amount of your employer provided benefits, less the first $1,000. Fill only if 'Will your (and your partner's) combined income in the current financial year be the same, higher or lower than it was in the financial year you indicated at question 26?' is 'Lower'.
Depends on: Lower
Reportable Superannuation Contributions (You) Number
Enter the sum of your reportable employer and personal deductible superannuation contributions. Fill only if 'Will your (and your partner's) combined income in the current financial year be the same, higher or lower than it was in the financial year you indicated at question 26?' is 'Lower'.
Depends on: Lower
Total Income (You) Number
Enter your total income, which is the sum of components A, B, C, D, and E. Fill only if 'Will your (and your partner's) combined income in the current financial year be the same, higher or lower than it was in the financial year you indicated at question 26?' is 'Lower'.
Depends on: Lower
Your Name
Mr Checkbox
Check this box if your title is Mr.
Mrs Checkbox
Check this box if your title is Mrs.
Miss Checkbox
Check this box if your title is Miss.
Ms Checkbox
Check this box if your title is Ms.
Mx Checkbox
Check this box if your title is Mx.
Other Title Text
Enter your title if it is not Mr, Mrs, Miss, Ms, or Mx. Fill only if 'Mr', 'Mrs', 'Miss', 'Ms', 'Mx' are all 'No'.
Depends on: Mr, Mrs, Miss, Ms, Mx
Family Name Text
Enter your family name.
First Given Name Text
Enter your first given name.
Second Given Name Text
Enter your second given name if you have one.
Your Other Names Declaration
No (You) Checkbox
Check this box if you have not been known by any other name(s).
Yes (You) Checkbox
Check this box if you have been known by other name(s) and need to provide details below.
Your Other Names Declaration Text
Please provide any other names you have been known by, such as names at birth, names before marriage, previous married names, Aboriginal or skin names, aliases, adoptive names, or foster names.
Your Partner's Contact Details
Partner's Home Phone Number Text
Enter your partner's home phone number. Fill only if 'Do you have a partner?' is 'Yes'.
Max length: 10 characters
Depends on: Yes
Silent number No Checkbox
Check this box if your partner's home phone number is not a silent number. Fill only if 'Do you have a partner?' is 'Yes'.
Depends on: Yes
Silent number Yes Checkbox
Check this box if your partner's home phone number is a silent number. Fill only if 'Do you have a partner?' is 'Yes'.
Depends on: Yes
Partner's Mobile Phone Number Text
Enter your partner's mobile phone number. Fill only if 'Do you have a partner?' is 'Yes'.
Max length: 10 characters
Depends on: Yes
Partner's Fax Number Text
Enter your partner's fax number. Fill only if 'Do you have a partner?' is 'Yes'.
Max length: 10 characters
Depends on: Yes
Partner's Work Phone Number Text
Enter your partner's work phone number. Fill only if 'Do you have a partner?' is 'Yes'.
Max length: 10 characters
Depends on: Yes
Partner's Alternative Phone Number Text
Enter your partner's alternative phone number. Fill only if 'Do you have a partner?' is 'Yes'.
Max length: 10 characters
Depends on: Yes
Partner's Email Text
Enter your partner's email address. Fill only if 'Do you have a partner?' is 'Yes'.
Depends on: Yes
Your Partner's Income Details
Partner's Estimated Taxable Income (Option 1) Number
Enter your partner's estimated taxable income for the current financial year. Fill only if 'Will your (and your partner's) combined income in the current financial year be the same, higher or lower than it was in the financial year you indicated at question 26?' is 'Lower'.
Depends on: Lower
Partner's Estimated Income (No Tax Return) Number
If your partner's income is too low and they are not required to lodge a tax return, enter the amount of income they expect to receive, excluding income from sources requested in Parts B to E. Fill only if 'Will your (and your partner's) combined income in the current financial year be the same, higher or lower than it was in the financial year you indicated at question 26?' is 'Lower'.
Depends on: Lower
Partner's Foreign Income Number
Enter your partner's foreign income on which Australian income tax is not paid, in Australian dollars. Fill only if 'Will your (and your partner's) combined income in the current financial year be the same, higher or lower than it was in the financial year you indicated at question 26?' is 'Lower'.
Depends on: Lower
Partner's Total Net Investment Loss Number
Enter your partner's total net investment loss, which is the sum of net rental property losses and net financial investment losses, adding this amount even though it is a loss. Fill only if 'Will your (and your partner's) combined income in the current financial year be the same, higher or lower than it was in the financial year you indicated at question 26?' is 'Lower'.
Depends on: Lower
Partner's Employer Provided Benefits Above $1,000 Number
Enter the total amount of your partner's employer-provided benefits that are above the first $1,000. Fill only if 'Will your (and your partner's) combined income in the current financial year be the same, higher or lower than it was in the financial year you indicated at question 26?' is 'Lower'.
Depends on: Lower
Partner's Reportable Superannuation Contributions Number
Enter your partner's total reportable superannuation contributions, including reportable employer superannuation contributions and personal deductible superannuation contributions. Fill only if 'Will your (and your partner's) combined income in the current financial year be the same, higher or lower than it was in the financial year you indicated at question 26?' is 'Lower'.
Depends on: Lower
Partner's Total Income Number
Enter your partner's total income, which is the sum of their estimated taxable income, foreign income, total net investment loss, value of employer provided benefits above $1,000, and reportable superannuation contributions. Fill only if 'Will your (and your partner's) combined income in the current financial year be the same, higher or lower than it was in the financial year you indicated at question 26?' is 'Lower'.
Depends on: Lower
Your Permanent Address
Q8Y.Address1 Text
Q8Y.Address2 Text
Q8Y.Address3 Text
Q8Y.Postcode Text
Max length: 4 characters
Your Permission for Partner to Speak on Your Behalf
No Checkbox
Check this box if you do not give permission for your partner to speak with us on your behalf. Fill only if 'Do you have a partner?' is 'Yes'.
Depends on: Yes
Yes Checkbox
Check this box if you give permission for your partner to speak with us on your behalf. Fill only if 'Do you have a partner?' is 'Yes'.
Depends on: Yes
Your Postal Address
Postal Address Line 1 Text
Please enter the first line of your postal address.
Postal Address Line 2 Text
Please enter the second line of your postal address.
Postal Address Suburb/City/State Text
Please enter the suburb, city, or state for your postal address.
Postal Address Postcode Text
Please enter the postcode for your postal address.
Max length: 4 characters
Your Prior Tax File Number Submission
No Checkbox
Check this box if you have not given us your tax file number before.
Not sure Checkbox
Check this box if you are unsure whether you have given us your tax file number before.
Yes Checkbox
Check this box if you have previously given us your tax file number.
DummyCalcQ17 Text
Your Second Other Name
Second Other Name Text
Please provide your second other name. Fill only if 'Yes (You)' is 'Yes'.
Depends on: Yes (You)
Second Other Name Type Text
Please specify the type of your second other name, such as name before marriage, name at birth, or an alias. Fill only if 'Yes (You)' is 'Yes'.
Depends on: Yes (You)
Your Tax File Number Details
No Checkbox
Check this box if you do not have a tax file number. Fill only if 'No', 'Not sure' is 'No' or 'Not sure' in question 17.
Depends on: No, Not sure
Yes Checkbox
Check this box if you have a tax file number and will provide it. Fill only if 'No', 'Not sure' is 'No' or 'Not sure' in question 17.
Depends on: No, Not sure
DummyCalcQ18 Text
Depends on: Yes
Tax File Number Part 1 Text
Enter the first three digits of your Australian Tax File Number. Fill only if 'Yes' is 'Yes' for question 18.
Max length: 3 characters
Depends on: Yes
Tax File Number Part 2 Text
Enter the second three digits of your Australian Tax File Number. Fill only if 'Yes' is 'Yes' for question 18.
Max length: 3 characters
Depends on: Yes
Tax File Number Part 3 Text
Enter the last three digits of your Australian Tax File Number. Fill only if 'Yes' is 'Yes' for question 18.
Max length: 3 characters
Depends on: Yes